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Recent  Decrease  in  Deaths  from  Diabetes  at  Massachusetts  General 
Hospital,  1824-1918.     See  Table  2,  page  23. 


A 


DIABETIC  MANUAL 


MUTUAL  USE  OF  DOCTOR  AND  PATIENT 


BY 

ELLIOTT  P.  JOSLIN,  M.D. 

ASSISTANT  PBOTESSOH  OF  MEDICINE,  HARVABD   MEDICAL   SCHOOL;   CONSULTING 

PHYSICIAN,  BOSTON  CITY  HOSPITAL;   COLLABORATOR   TO   THE   NUTRITION 

LABORATORY  OF  THE  CARNEGIE  INSTITOTION  OF  WASHINGTON, 

IN   boston;    FORMERLY  LIEUTENANT-COLONEL,  M.  C, 

U.  S.  ARMY 


UlluetrateD 


f^^;^     il,  E.  HALS 
nM  ST. 


SECOND  EDITION,  THOROUGHLY  REVISED 


LEA   &   FEBIGER 

PHILADELPHIA    AND    NEW    YORK 
1919 


Copyright 
LEA  &  FEBIGER 

1919 


11 


TO 

HELP  MAKE   THE  HOME 

SAFE  FOR  THE 

DIABETIC 

IS  THE   OBJECT   OF 

THIS  BOOK. 


PREFACE  TO  THE  SECOND  EDITION. 


The  first  edition  of  this  book  was  written  just  prior  to 
the  entrance  of  the  writer  into  the  army  and  was  reprinted 
before  his  discharge.  Though  compiled  under  unfavorable 
conditions  it  evidently  met  a  need.  However,  the  treat- 
ment of  diabetes  is  improving  and  to  keep  pace  with  the 
advance  this  edition  has  been  prepared.  The  Manual 
has  been  thoroughly  revised,  condensed  and  simplified, 
with  the  renewed  purpose  to  make  it  serve  as  a  text-book 
for  the  physician  to  use  in  the  education  of  his  patients. 
The  growing  number  is  already  too  great  to  permit  of 
adequate  treatment  without  some  such  assistance.  I  still 
feel  that  for  one  diabetic  patient  who  learns  too  much 
about  the  disease,  there  are  unquestionably  ninety-nine  who 
know  too  little.  Those  of  my  patients  who  are  the  most 
intelligent  and  those  who  understand  the  disease  the  best 
live  the  longest. 

There  is  no  satisfaction  in  treating  ignorant  diabetics. 
The  possibility  exists  of  bringing  the  knowledge  of  each  one 
up  to  such  a  point  that  he  will  not  only  cooperate,  but  be 
able  to  ask  questions  which  are  both  stimulating  and  search- 
ing.   In  this  way  we  physicians  will  be  forced  to  forge  ahead. 

I  wish  the  faithful  laboratory  workers  in  our  medical 
schools  could  have  the  pleasure  of  watching  a  diabetic 
patient  improve.  They  have  done  so  much  to  help  the 
diabetic  and  yet  they  miss  the  enjoyment  of  seeing  what  is 
being  accomplished.    It  is  from  the  scientific  investigations 

(vii) 


viil  PREFACE  TO   THE  SECOND  EDITION 

in  laboratories  that  new  clisco\eries  for  diabetics  Avill  come. 
Patients,  and  practising  physicians  as  well,  should  realize 
their  opportunity  of  helping  themsehes  by  fostering  labora- 
tory research  upon  diabetes. 

To  the  many  friends  who  haAc  given  suggestions,  to  that 
one  rare  fririid  who  offered  criticisms,  to  my  assistant  Dr. 
Albert  A.  Hornor  and  to  my  secretary,  Miss  Anna  Holt, 
I  am  most  grateful. 

Elliott  P.  Josux. 


CONTENTS. 


CHAPTER  I. 
Diabetes ■        1^ 

CHAPTER  II. 

The  Recent  Improvement  in  Diabetic  Treatment    ...       23 

CHAPTER  III. 

Questions  and  Answers  for  Diabetic  Patients    .      .      •      -27 

CHAPTER  IV. 
Diabetic  Arithmetic  .  - 34 

CHAPTER  V. 

Efficiency  in  Visits  to  a  Doctor 43 

CHAPTER  VI. 

Hygiene  for  the  Diabetic 46 

CHAPTER  VII. 
The  Diet  of  Normal  Individuals 50 

CHAPTER  VIII. 
The  Diet  of  Diabetic  Individuals 61 

CHAPTER  IX. 

The  Dietetic  Treatment  of  Diabetic  Individuals    .  76 

Introduction 76 

Summary  of  Test  Diets 79 

Description  of  Special  Cases 90 

Explanation  of  the  General  Principles  Underlying  the  Treatment 

of  Moderately  Severe  Cases  of  Diabetes 93 

(ix) 


X  CONTENTS 

CHAPTER  X. 

Acid  Intoxication;  Acidosis;  Diabetic  Coma 108 

CHAPTER   XI. 
Weight  Peculi^vrities Ill 

CHAPTER  XII. 
The  Diabetic  Diet  is  Expensive 118 

CHAPTER  XIII. 
Care  of  the  Teeth 122 

CHAPTER  XIV. 
Care  of  the  Skin 125 

CHAPTER  XV. 
Treatment  of  Constipation  and  Diarrhea 127 

CHAPTER  XVI. 
Drugs  in  the  Treatment  of  Diabetes 129 

CHAPTER  XVII. 
Dietetic  Suggestions,  Recipes  and  Menus 130 

CHAPTER  XVIII. 
Diet  Tables 151 

CHAPTER  XIX. 

Selected  Labor.\tory  Tests  Useful  in  Diabetic  Treatment     170 


DIABETIC  MANUAL. 


CHAPTER   I. 

DIABETES. 

Diabetes  is  a  disease  which  has  a  pecuhar  fascination 
for  all  who  come  in  contact  with  it.  No  malady  to  which 
human  flesh  is  heir,  in  comparison  with  the  number  of 
individuals  involved,  has  attracted  as  much  attention. 
And  while  the  riddle  of  diabetes  is  far  from  being  solved, 
the  studies  made  upon  it  have  been  of  inestimable  value  in 
throwing  light  upon  many  of  the  intricate  processes  which 
are  continually  going  on  in  the  body  and  have  also  brought 
about  improvement  in  the  treatment  of  the  disease  itself. 
In  diabetes  the  chemist  always  finds  problems  beguiling  him 
by  their  apparent  simplicity  and  tempting  him  on  to  their 
elucidation;  and  if  one  has  a  statistical  bent,  the  lure  of 
accumulating  columns  of  figures,  recording  the  results  of 
many  tests,  will  so  engross  the  attention  that,  like  the  miser 
counting  his  gold,  one  will  often  find  himself  poring  over 
them  without  appreciating  their  true  significance.  In  dia- 
betes the  physician  has  an  opportunity  to  observe  such 
concrete  results  from  a  few  words  of  careful  advice  upon  diet 
to  his  patient  as  to  compensate  him  for  the  time  spent  upon 
many  needless  ills  and  encourage  him  always  to  practice 
scientific  rather  than  empirical  medicine.  And  as  for  the 
patient,  the  first  effects  of  treatment  appear  to  him  so 
magical  that  he  can  hardly  believe  them  to  be  explained 
by  the  simple  measures  he  has  adopted.  Indeed,  with 
the  slightest  hint  he  is  eager  to  attribute  them  to  the  most 
improbable  sources. 

2  (17) 


18  DIABETES 

It  is  perfectly  true  that  diabetes  is  a  chronic  disease,  but, 
unlike  rheumatism  and  cancer,  it  is  painless;  unlike  tuber- 
culosis, it  is  clean  and  not  contagious,  and  in  contrast  to 
many  diseases  of  the  skin,  it  is  not  unsightly.  jMoreover,  it 
is  susceptible  to  treatment,  and  the  downward  coiu*se  of  a 
patient  can  usually  be  promptly  checked.  Treatment,  how- 
ever, is  b}'-  diet  and  not  by  drugs,  and  the  patients  who  know 
the  most,  conditions  being  equal,  can  live  the  longest.  There 
is  no  disease  in  which  an  understanding  by  the  patient  of 
the  methods  of  treatment  avails  as  much.  Brains  count. 
But  loiowledge  alone  will  not  save  the  diabetic.  This  is  a 
disease  which  tests  the  character  of  the  patient,  and  for 
success  in  withstanding  it,  in  addition  to  Avisdom,  he  must 
possess  honesty,  self-control  and  courage.  Already  34  of  my 
patients  have  lived  longer  than  would  have  been  expected  of 
them  had  they  been  normal,  healthy  people.  For  the  diabetic 
this  is  a  demonstration  and  a  challenge. 

The  underlying  cause  of  diabetes  is  usually  considered 
to  be  a  derangement  in  one  of  the  fimctions  of  the  pancreas. 
This  is  a  gland,  in  animals  known  as  the  sweetbread,  which 
lies  behind  the  stomach  near  the  liver.  It  discharges  into  the 
bowel  the  most  important  digestive  juice  of  any  gland  in 
the  body,  and  this  juice  is  capable  of  digesting  all  kinds  of 
food.  Strangely  enough  this  digestive  action  of  the  pancreas 
remains  undisturbed  in  diabetes.  The  fault  with  the  pan- 
creas in  diabetes  concerns  that  function  of  the  gland  which 
regulates  the  body's  use  of  the  sugar  formed  from  the  food. 
This  function  appears  to  reside  in  groups  of  cells  distributed 
throughout  the  pancreas  and  called  the  "islands  of  Langer- 
hans."  When  these  cells  have  been  found  to  be  diseased  a 
history  of  diabetes  has  been  usually  demonstrable.  These 
groups  of  cells  probably  manufacture  a  special  internal 
secretion  which  is  discharged  into  the  blood.  Experimentally, 
with  animals,  it  is  easy  to  produce  diabetes  by  simply 
removing  a  large  portion  of  the  pancreas,  and  the  severity 
of  the  diabetes  so  produced  is  proportional  to  the  amount  of 
the  gland  removed.  If  the  diabetic  patient  could  secure  a  new 
pancreatic  gland  he  would  be  cured. 

As  yet  all  attempts  to  treat  diabetes  successfully  by  feeding 


DIABETES  19 

patients  the  healthy  pancreatic  glands  of  animals,  by  the 
use  of  extracts  made  from  the  gland  or  by  grafting  portions 
of  a  healthy  gland  under  the  skin,  have  failed.  Nevertheless, 
it  is  hoped  that  some  measure  of  success  will  be  achieved 
eventually  along  these  lines. 

Granted  there  is  a  natural  tendency  to  diabetes  in  certain 
individuals,  this  develops  into  the  actual  disease  rnost 
commonly  when  the  body  is  overfed.  Approximately  60 
per  cent,  of  a  recent  series  of  100  diabetic  cases  showed 
obesity.  The  average  number  of  pounds  overweight  for  a 
group  of  457  diabetic  patients  for  different  ages  is  shown  in 
Table  1. 

Table  1. — Overweight  Usually  Precedes  Diabetes. 


Age  in  years. 

Number  of  cases. 

Average  number  of 
pounds  overweight. 

12  to  24 
25  to  29 
30  to  39 
39  and  over 

38 

27 

72 

320 

3 

54 
23 
37 

Lack  of  exercise  is,  of  course,  a  factor  in  producing  the  con- 
dition of  overweight,  and  thus  is  an  indirect  cause  of  diabetes. 
Disuse  of  the  muscles,  however,  is  itself  a  direct  factor,  for 
it  is  largely  in  these  that  the  sugar  formed  from  the  food  is 
consumed.  That  man  who  gives  up  an  active  outdoor  life 
and  is  promoted  to  an  ofRce  chair  by  this  change  becomes  a 
promising  candidate  for  diabetes.  If  the  overfeeding  has  been 
in  the  form  of  sugar,  predisposition  to  diabetes  is  greater. 
There  is  real  danger  in  the  candy  habit.  It  is  possible  that 
the  recent  increase  in  the  quantity  of  sugar  consumed  per 
capita  in  the  United  States  has  increased  our  niunber  of 
diabetics.  Between  1800  and  1810  the  average  consiunption 
of  sugar  by  each  individual  in  the  United  States  was  11 
pounds  a  year,  but  between  1910  and  1917  it  was  73  pounds, 
and  Mr.  Hoover  is  credited  in  the  daily  papers  for  September, 
1917,  with  showing  this  figure  for  1916  to  be  90  pounds. 

No  other  condition  rivals  obesity  in  importance  as  a  fore- 
runner of  diabetes,  but  a  strenuous,  mental  life  is  probably 
of  some  significance.  This  appears  reasonable,  for  it  has 
been  shown  that  medical  students,  after  three-hour  written 


20  DIABETES 

examinations  upon  which  their  promotion  for  a  year  depends, 
often  show  sup;ar  in  the  urine  immediately  thereafter,  and 
it  may  not  be  a  chance  coincidence  that  during  one  year 
three  children  were  under  my  care  for  diabetes  who  had 
recently  led  their  respective  classes  at  school.  Another 
illustration  of  this  tendency  is  Case  No.  1380,  a  child  who 
came  to  the  office  showing  0.2  per  cent,  of  sugar.  She  had 
skipped  two  classes  at  school,  and  the  following  summer  had 
eaten  even  more  than  her  habitually  large  amoimt  of  sweets 
and  candy. 

In  the  presence  of  an  infectious  disease,  for  example  tonsil- 
litis, an  existing  diabetes  grows  worse;  but  it  is  yet  to  be 
demonstrated  that  diabetes  frequently  occm-s  as  the  result 
of  an  infection. 

Of  my  cases,  only  21  per  cent,  show  a  history  of  diabetes 
in  their  families,  i.  e.,  that  the  disease  has  been  present  in 
parents,  brothers  or  sisters. 

Hereditary  cases  are  usually  mild.  With  the  avoidance  of 
obesity  and  with  moderation  in  the  use  of  sweet  food  the 
children  of  diabetics  may  be  no  more  liable  to  the  disease 
than  other  children.  Particularly  should  the  urines  of  such 
individuals  be  carefully  examined  when  conditions  arise 
which  would  favor  the  development  of  diabetes. 

It  w'ould  be  a  great  mistake  to  consider  the  diet  alone 
of  importance.  ]MentaI  relaxation  and  physical  exercise 
should  be  promoted.  If  we  are  to  bring  about  a  decrease  of 
diabetes  in  the  community  it  will  be  with  measures  such  as 
these.  Every  agency  which  promotes  health  and  physical 
development  tends  to  prevent  an  outbreak  of  the  diabetic 
tendency.     "It  is  easier  to  keep  well  than  to  get  well." 

The  disease  sugar  diabetes,  usually  known  by  its  Latin 
name,  "diabetes  mellitus,"  is  revealed  when  sugar  is  found 
in  the  urine.  The  development  of  the  disease  may  be  gradual 
or  acute,  and  with  or  without  symptoms.  It  is  fortunate 
that  the  disease  can  be  so  readily  discovered,  for  unlike  many 
diseases  whose  beginnings  can  be  detected  only  by  specialists 
or  disclosed  by  the  help  of  elaborate  and  expensive  methods, 
such  as  the  Roentgen  rays,  diabetes  can  be  easily  and  promptly 
recognized  by  any  physician  who  will  be  on  the  watch  for  it 


DIABETES  21 

and  will  examine  the  urine  of  his  patient  for  sugar.  The 
subsequent  behavior  of  the  disease  and  the  effect  of  treat- 
ment are  also  easily  regulated  by  simple  examinations,  and 
herein  the  diabetic  has  a  great  advantage  over  many  another 
patient. 

The  sugar  in  the  urine  of  diabetic  patients  is  derived  from 
the  food,  and  chiefly  from  that  consumed  within  the  pre- 
ceding twenty-four  hours.  The  effects  of  a  meal  begin  to 
show  within  ten  minutes  by  an  increase  of  sugar  in  the 
blood  or  by  the  appearance  of  sugar  in  the  urine.  Most 
of  the  sugar  in  the  urine  comes  from  carbohydrate  (sugar 
and  starch),  but  in  extremely  severe  cases  as  much  as  60 
per  cent,  of  the  protein  (examples  of  which  are  lean  of  meat 
and  fish,  white  of  egg  and  curd  of  milk)  in  the  diet  may  change 
to  sugar.  No  sugar  is  formed  from  fat,  but  if  a  diabetic  eats 
too  much  fat  he  utilizes  the  carbohydrate  and  protein  of  the 
diet  less  well. 

Improvement  in  diabetes  takes  place  when  the  lu-ine  is 
kept  free  from  sugar.  The  annoying  symptoms  of  the  un- 
treated diabetic  then  vanish.  Under  such  conditions  the 
power  of  the  pancreas  to  assimilate  carbohydrate  is  increased. 
Conversely,  if  the  urine  is  not  free  from  sugar  the  patient  is 
generally  only  holding  his  own,  or  more  likely  is  growing 
worse.  Professor  Naunyn,  who  for  a  generation  was  perhaps 
the  leading  specialist  in  diabetes,  observed  that  even  severe 
cases  if  treated  early  did  well,  whereas  mild  cases  if  neglected 
usually  did  poorly. 

Examinations  of  the  blood  for  sugar  give  valuable  infor- 
mation in  the  treatment  of  diabetes.  The  sugar  in  the  blood 
usually  rises  above  normal  before  sugar  in  the  urine  appears. 
Consequently,  if  information  can  be  learned  about  the  blood 
sugar,  one  often  anticipates  the  information  which  an 
examination  of  the  urine  alone  would  show.  The  knowledge 
about  the  blood  sugar  is  still  fragmentary,  and  it  must  be 
acknowledged  that  many  cases  of  diabetes  have  lived  com- 
fortably without  a  single  blood  sugar  estimation.  However, 
analyses  of  the  blood  sugar  now  appear  to  be  of  much  value. 

In  what  follow^s  an  attempt  will  be  made  to  show  how  to 
treat  the  disease,  and  since  success  in  treatment  is  most  easily 


22  DIABETES 

attained  by  the  selection  of  a  diet  which  will  keep  the  urine 
sugar-free,  detailed  advice  along  dietetic  lines  will  be  given. 
The  responsibility  for  niahitaining  this  favorable  state  must 
rest  in  large  measure  upon  the  patient  himself.  He  must 
learn  what  diet  is  best  for  him  and  must  constantly  control 
his  condition  by  the  examination  of  his  lu'ine.  He  is  his  own 
muse,  doctor's  assistant  and  chemist.  If  he  tries  to  be  his 
own  doctor  he  will  come  to  grief.  To  acquire  the  requisite 
knowledge  for  this  triple  vocation  requires  diligent  study, 
but  the  prize  offered  is  worth  while,  for  it  is  nothing  less  than 
life  itself. 


CHAPTER   II. 

THE  RECENT  IMPROVEMENT  IN  DIABETIC 
TREATMENT. 

One  often  hears  the  remark  that  patients  with  diabetes 
Hve  for  years,  with  Httle  inconvenience  to  themselves,  even 
though  strict  rules  of  diet  are  neglected.  This  may  be  a 
consoling  thought  to  some  weak-willed  patient,  but  if  the 
average  diabetic  yields  to  such  seductive  advice  the  proba- 
bility is  overwhelming  that  he  will  later  pay  the  penalty. 
Furthermore,  such  statements  are  not  true.  Their  origin 
lies  in  the  favorable  course  of  the  large  number  of  mild  cases 
of  diabetes,  but  just  as  it  is  a  serious  blunder  in  war  to 
disparage  the  strength  of  the  enemy,  so  it  is  in  diabetes. 

Table  2. — The  Recent  Improvement  in  Diabetic  Treatment  as 

Shown  by  the  Statistics  of  the  Massachusetts 

General  Hospital. 

Period. 
1824  to  1898 
1898  to  1914 

1914 

1915 

1916 

1917 

1918  108  4  4 

How  serious  in  the  past  diabetes  has  really  been,  and  at  the 
same  time  how  much  the  methods  of  treatment  have  improved 
during  the  recent  years,  is  best  shown  by  the  statistics  for 
diabetes  of  the  Massachusetts  General  Hospital.  These 
.statistics  are  incorporated  in  Table  2.  No  student  of 
medicine,  practitioner,  patient  or  investigator  can  fail  to 
be  impressed  by  them  or  to  gather  hope  for  the  futm'e  from 
this  steady  reduction  in  mortality.     It  is  gratifying"  that 

(23) 


umber  of 

Mortality  during  hospital  stay. 

cases. 

Number  of 

deaths. 

Per  cent. 

172 

47 

27 

284 

80 

28 

51 

8 

16 

89 

11 

12 

103 

8 

8 

105 

6 

6 

24      liECENT  Uf  PROVE  MEN  T  IN  DIABETIC  TREATMENT 

this  advance  has  conio  through  hard  work  and  not  througli 
chance,  and  that  multitudes  of  scientific  men  and  -women 
have  shared  in  it.  All  Avill  gladly  acknoAvledge  the  impor- 
tant part  which  Dr.  Frederick  M.  Allen,  ft)rmerly  of  the 
Rockefeller  Institute  for  ^Medical  Research,  has  taken  in 
bringing  this  about. 

These  figures  are  far  more  valuable  than  those  of  a  single 
individual.  Confirmatory  of  the  Massachusetts  General 
Hospital  statistics,  however,  are  those  of  m}^  own  cases 
treated  at  the  Corey  Hill  Hospital  and  the  New  England 
Deaconess  Hospital  between  .January,  1913,  and  January, 
191 S,  as  shown  in  Talkie  '.]. 

Table  3. — INIortality   among'  Author's   Cases  Treated   at  the 

Corey  Hill  and  New  England  Deaconess  Hospitals, 

January,  1913,  to  November,  1919. 


Number  of 

jMortality  during 

hospital  stay. 

Year. 

cases. 

Number  of  deaths. 

Per  cent. 

1913 

43 

4 

9 

1914 

60 

3 

5 

1915 

109 

6 

6 

1916 

164 

8 

5 

1917 

181 

4 

2 

19181 

23 

0 

0 

19192 

105 

2 

2 

The  improvement  may  be  attributed  to  (1)  the  introduc- 
tion of  newer  methods  of  treatment  inaugurated  by  Dr. 
Allen;  (2)  more  accurate  tests  for  the  estimation  of  the 
severity  of  acid  poisoning — that  arch  enemy  of  the  dia- 
betic; (.3)  the  preliminary  omission  of  fat  prior  to  any  change 
in  diet;  (4)  the  omission  of  alkalies. 

What  acute  or  chronic  disease  can  show  an  advance  in 
treatment  comparable  to  that  demonstrated  in  Tables  2 
and  3  during  the  last  three  years? 

The  improvement  in  treatment  which  will  accrue  from 
examinations  of  sugar  in  the  })lood  will  appear  later.  In 
1916,  28  cases  were  published,  showing  an  average  of  0.22 
per  cent,  sugar  in  the  blood  upon  admission  to  the  hospital. 

'February  6,   1918,  to  March  1,  1919,  ab.sent  on  duty.  Medical    Corps, 
U.  S.  ArmJ^ 
2  Resumed  practice  April  1,  1919:  April  1,  1919  to  November  1,  1919. 


RECENT  IMPROVEMENT  IN  DIABETIC  TREATMENT     25 

The  normal  quantity  of  sugar  in  the  blood  is  O.KJ  per  cent. 
At  that  time  the  percentage  of  sugar  in  the  blood  at  discharge 
was  0.20  per  cent.  In  1917,  04  eases  were  reported.  The 
average  blood  sugar  on  admission  was  0.24  per  cent.,  upon 
discharge  0.19  per  cent.  During  seven  months  of  1919  the 
figures  for  93  patients  are  now  available.  They  show,  as 
compared  with  the  above  data,  0.20  per  cent,  on  entrance 
and  0.14  per  cent,  upon  discharge.  Patients  now  leave  the 
hospital  in  safer  condition  than  ever  before.  This  is  due  to 
the  protection  afforded  by  the  knowledge  gained  through 
repeated  blood  sugar  estimations. 

The  need  of  further  improvement  in  the  treatment  of  severe 
diabetes  still  exists.  This  fact  must  be  courageously  faced. 
The  prevention  of  acid  intoxication  is  an  important  victory 
yet  to  be  won.  This  will  be  borne  in  mind  in  all  that  follows 
about  treatment,  but  for  a  summary  of  the  nature  of  acid 
poisoning,  its  cause  and  the  measures  now  available  to 
combat  it,  see  page  108. 

Hospital  statistics  demonstrate  that  the  opportunity  for 
further  improvement  in  the  treatment  of  diabetes  lies  not 
in  the  hospital  but  in  the  home.  To  this  end  a  campaign 
must  be  aggressively  waged.  If  the  mortality  can  be 
reduced  nearly  to  zero  in  the  hospital,  these  same  results 
ought  to  be  attained  outside  of  the  hospital,  for  there  is  no 
reason  why  the  methods  which  have  made  hospital  treat- 
ment comparatively  safe  should  not  be  employed  in  making 
treatment  in  the  home  safe.  It  is  unreasonable  to  expect  that 
the  ultimate  diabetic  mortality  in  the  home  will  be  as  low 
as  that  in  the  hospital,  because  of  the  shorter  duration  of 
stay 'in  the  latter,  but  the  time  has  arrived  when  the  acci- 
dental and  avoidable  deaths  which  have  now  been  largely 
eliminated  from  the  statistics  of  the  best  hospitals  should 
also  be  eliminated  from  private  practice.  The  secret  of  the 
success  of  hospital  improvement  lies  in  the  close  and  continu- 
ous observation  of  the  patient  by  the  doctor.  For  success 
in  home  treatment,  close  and  continuous  observation  of  the 
patient  by  the  doctor  is  just  as  essential.  My  assistant  of 
several  years  ago.  Dr.  F.  Gorham  Brigham,  has  taken  pains 
to  bring  this  about  in  his  systematic  manner  by  having  all 


26     RECENT  IMPROVEMENT  IN  DIABETIC  TREATMENT 

his  diabetic  patients  report  at  stated  interA-als,  sometimes 
long,  sometimes  short,  for  observation. 

Two  reasons  ha^•e  prevented  iloctors  in  the  past  from 
m-ging  patients  to  return  for  treatment.  Prior  to  1914, 
before  the  time  of  striking  improvement  in  diabetes  existed, 
physicians  feared  that  new  suggestions  might  make  a 
patient,  apparently  doing  well,  get  worse,  and  it  was  con- 
sidered safer  to  let  well  enough  alone.  In  the  second  place 
physicians  hesitated  to  ask  patients  to  return  for  fear  of 
being  considered  commercial.  Today,  with  the  more  wide- 
spread knowledge  concerning  this  disease,  both  on  the  part 
of  the  doctor  and  patient,  these  two  objections  will  vanish. 


Per 

ceni 
?0 

-^ 

^-^ 

—^ 

^ 

^ 

^ 

y^ 

in 

^ 

y 

J-* 

^ 

-L--^ 

^ 

^ 

0 

1880 


1890 


1900 


1910  1916 

The  rising  rate  of  deaths  from  diabetes  per  100,000  between  the  years 
1880  and  1917  in  the  registration  area  of  the  United  States. 


CHAPTER   III. 

QUESTIONS  AND  ANSWERS  FOR  DIABETIC 
PATIENTS. 

Knowledge  Essential  for  a  Diabetic. — The  treatment  of  a 
patient  with  diabetes  lasts  through  Hfe.  All  too  often  in 
recent  years  it  has  been  felt  that  if  the  urine  were  rendered 
sugar-free  by  fasting,  the  treatment  of  the  diabetic  ended; 
in  reality  it  has  hardly  begun.  Treatment  must  therefore  be 
adjusted  to  the  condition  of  the  patient,  and  should  be  so 
arranged  that  it  can  be  continued  for  years  not  only  without 
harm,  but  with  as  little  annoyance  or  interference  with  the 
daily  routine  as  is  possible.  Consequently,  the  patient  must 
be  taught  the  nature  of  his  disease  and  how  to  conquer  it. 

In  the  following  questions  and  answers  an  attempt  is  made 
to  indicate  the  essential  features  of  the  knowledge  desirable 
for  a  diabetic  patient. 

1.  Question.    Why  does  the  human  body  need  food? 
Ans.     To  furnish  heat,  repair  waste,  permit  growth,  and 

exercise. 

2.  Question.  How  may  the  many  varieties  of  food  be 
simply  classified  ? 

Ans.    Carbohydrate,  protein  and  fat,  also  water  and  salts. 

(a)  Question.  Upon  what  does  the  nutritive  value  of 
food  depend  ? 
Ans.  The  quantity  of  carbohydrate,  protein  and  fat  which 
it  contains. 

(6)  Question.    W^hat  is  carbohydrate? 
Ans.     It  occurs  in  many  forms,  but  examples  of  it  are 
sugar  and  starch.    Cane  sugar  is  the  commonest  sugar.    A 

(27) 


2S        QUESTIONS  AND  ANSWERS  FOR  DIABETICS 

pure  form  of  starch  is  corn  starch.  Fruits  arc  ahnost  entirely 
water  and  sugar  and  vegetables  are  largely  water  and  starch. 
Bananas,  when  green,  contain  nearly  20  per  cent,  starch,  but 
when  ripened  this  changes  to  sugar.  Starchy  foods  during 
digestion  in  the  body  rapidly  change  to  sugar,  and  conse- 
quently these  two  foods  are  nearh'  interchangeable.  Pota- 
toes are  20  per  cent,  starch.  Bread  is  about  55  per  cent, 
starch,  and  the  flour  out  of  which  it  is  made,  being  drier 
than  the  bread,  contains  about  70  per  cent.  Oatmeal  is 
two-thirds  starch,  but  other  cereals  contain  rather  more. 
Milk  contains  5  per  cent,  of  sugar.  Meat,  fish  and  eggs  are 
entirely  free  from  carbohydrate,  save  for  an  extremely  small 
percentage  of  animal  starch  (glycogen)  to  be  found  in  liver. 
The  quantity  of  carbohydrate  in  various  foods  is  graphically 
shown  in  Fig.  6,  page  51,  and  also  in  Table  6,  page  39. 

(c)  Question.  What  is  protein? 
Answer.  Protein  is  the  food  from  which  muscles  and 
tissues  are  made.  It  is  therefore  an  essential  constituent  of 
the  diet.  Examples  of  protein  are  lean  of  meat  or  fish,  curd 
of  milk  and  white  of  egg.  The  yolk  contains  just  as  much 
protein  as  the  white,  but  it  is  mixed  with  fat.  Protein  is  also 
found  in  grains,  and  there  is  considerable  in  beans  and  peas, 
but  very  little  in  other  vegetables,  and  almost  none  in  fruits. 

(f/)  Question.  What  is  fat? 
Ans.  Examples  of  fat  in  its  pure  form  are  oil  and  lard. 
Butter  and  substitutes  for  it  contain  85  per  cent.  fat.  Rich 
cream  contains  about  40  per  cent,  fat,  whereas  milk  may 
contain  but  3  per  cent.  Common  cheese  is  one-third  fat. 
The  percentage  of  fat  in  meat  varies  from  that  in  fat  bacon, 
in  which  the  percentage  occasionally  rises  to  80,  to  chicken, 
in  which  the  percentage  of  fat  is  3  or  less.  In  codfish  and 
haddock  the  amount  of  fat  is  negligible,  but  in  salmon  it 
reaches  13  per  cent.  Nuts  are  rich  in  fat.  Fat  and  carbo- 
hydrate are  to  a  large  extent  interchangeable.  In  northern 
climates  fat  forms  a  large  part  of  the  diet,  while  in  the  tropics 
it  is  replaced  by  carbohydrate. 


KNOWLEDGE  ESSENTIAL  FOR  A  DIABETIC         29 

3.  Question.  Should  the  diabetic  patient  know  about 
foods  and  their  relative  values? 

Ans.  Yes.  It  is  of  the  utmost  importance  for  him  to  know 
these  things,  since  (a)  diabetes  is  a  condition  in  which  the 
normal  utilization  of  carbohydrate  is  impaired,  and  (h)  the 
disease  is  usually  due  to  overeating.  Table  6  contains,  a  list 
of  foods  which  are  most  commonly  eaten  by  diabetic  patients, 
and,  indeed,  by  normal  individuals.  It  will  repay  study. 
Anyone  who  masters  this  table  will  know  how  to  secure  a 
diet  containing  the  desired  amount  of  carbohydrate,  protein 
and  fat. 

4.  Question.  What  is  the  proof  that  the  diabetic  does 
not  make  normal  use  of  the  carbohydrate  eaten? 

Ans.     The  appearance  of  sugar  in  the  urine. 

5.  Question.    How  much  sugar  is  lost  in  the  urine? 
Ans.     From  a  mere  trace  to  two  pounds  in  the  twenty-four 

hours   (Fig.   13,  page   120).     The  percentage   in  the  urine 
seldom  amounts  to  as  much  as  10  per  cent. 

6.  Question.    How  is  the  urine  tested  for  sugar? 

Ans.  In  many  ways.  The  Benedict  test  is  one  of  the 
most  reliable  (page  175). 

7.  Question.  Why  are  untreated  diabetics  unusually 
hungry? 

Ans.  Because  they  must  eat  enough  to  sustain  life  and  in 
addition  enough  to  make  up  for  the  sugar  lost  in  the  urine 
(pages  118-120). 

8.  Question.    Why  are  diabetics  abnormally  thirsty? 
Ans.     Because  they  must  produce  enough  urine  to  dissolve 

the  sugar  and  thus  remove  it  from  the  body. 

9.  Question.    What  is  the  aim  of  treatment? 

Ans.  The  improvement  of  the  condition  of  the  patient, 
which  is  best  indicated  by  the  excretion  of  urine  which  is 
sugar-free  and  by  a  normal  quantity  of  sugar  in  the  blood. 
See  Question  14. 


30        QUESTIONS  AND  ANSWERS  FOR  DIABETICS 

10.  Question.  What  is  the  nature  of  the  treatment? 
Ans.    Restriction  of  the  variety  and  quantity  of  the  food 

to  such  an  extent  as  will  remove  sugar  from  the  urine;  the 
cultivation  of  the  simple  life  and  moderate,  regular  exercise. 

11.  Question.     What  are  the  sources  of  sugar  in  the  urine? 
Ans.    First,  the  carbohydrate  in  the  diet;    second,    the 

protein.  From  100  grams  of  protein  it  is  theoretically  pos- 
sible to  form  58  grams  of  sugar. 

12.  Question.     How  else  can  sugar  appear  in  the  urine? 
Ans.    There  is  a  small  quantity  of  carbohydrate  stored  in 

the  body,  especially  in  the  muscles,  liver  and  blood.  This 
may  lead  to  the  excretion  of  sugar.  The  protein  which  forms 
the  tissues  of  the  body  may  also  be  drawn  upon  for  food, 
and  just  as  any  other  protein  may  be  incompletely  assimi- 
lated and  a  portion  appear  in  the  urine  as  sugar. 

13.  Question.     Is  sugar  formed  from  fat  or  alcohol? 
Ans.    Directly,  no,  but  indirectly,  yes.     If  a  patient  is 

sugar-free  upon  a  diet  containing  a  given  quantity  of  carbo- 
hydrate, protein  and  fat  it  is  possible  to  cause  sugar  to  appear 
in  the  urine  by  the  addition  to  the  diet  of  considerable  quanti- 
ties of  fat  or  alcohol.  Apparently  whenever  the  total  diet 
is  in  excess,  irrespective  of  any  particular  food,  the  power 
of  the  body  to  assimilate  carbohydrate  lessens.  Hence  the 
danger  to  the  diabetic  in  overfeeding. 

14.  Question.  Is  sugar  present  in  the  blood  of  healthy 
people  ? 

Ans.  Yes.  It  amounts  to  about  0.10  per  cent,  normally 
if  the  blood  is  examined  before  breakfast.  After  a  meal  the 
percentage  increases  to  about  0.14  per  cent.,  but  drops  to 
normal  within  approximately  two  hom-s. 

15.  Question.  Why  is  the  blood  tested  for  sugar  if  the 
urine  is  known  to  be  sugar-free? 

Ans.  To  determine  whether  the  diet  should  be  increased. 
The  results  of  a  faulty  diet  can  be  detected  earlier  in  the 


KNOWLEDGE  ESSENTIAL  FOR  A  DIABETIC        31 

blood  than  in  the  urine.    The  diet  should  not  be  increased, 
as  a  rule,  unless  the  blood  sugar  is  normal. 

16.  Question.  Is  treatment  of  diabetes  beneficial? 

Ans.  Yes.  In  the  large  majority  of  instances  it  cures 
disagreeable  symptoms;  it  prevents  dangerous  and  painful 
complications;  it  prolongs  life  and  enables  one  to  lead  an 
almost  normal  existence.  If  treatment  is  not  followed  the 
diabetes  grows  worse. 

17.  Question.  How  does  the  diabetic  diet  differ  from  the 
normal  diet? 

Ans.  By  the  smaller  quantity  of  carbohydrate,  fewer 
calories  and  the  greater  quantity  of  fat  (Fig.  11,  page  61). 

18.  Question.  How  many  calories  are  produced  in  the 
body  by  the  utilization  or  oxidation  of  1  gram  of  carbohy- 
drate, protein  and  fat? 

Ans.     1  gram  carbohydrate  produces  4  calories. 
1  gram  protein  produces  4  calories. 

1  gram  fat  produces  9  calories. 

1  gram  alcohol  produces  7  calories. 

19.  Question.  How  much  food  does  a  diabetic  patient 
need? 

Ans.  About  20  to  30  calories  per  kilogram  body  weight 
or  10  to  14  calories  per  pound.  This  is  a  little  less  than  for 
the  ordinary  individual. 

20.  Question.  How  can  sugar  be  removed  from  the  urine, 
or,  in  other  words,  the  patient  become  sugar-free? 

Ans.  In  mild  cases  by  eating  less  and  exercising  more, 
with  a  consequent  loss  of  weight.  In  moderate  cases  by  still 
greater  care  in  avoiding  unnecessary  food  and  often  by 
reducing  the  quantity  of  carbohydrate,  protein  and  fat.  In 
severe  cases  by  omitting  the  fat  from  the  diet,  by  which  pro- 
cedure the  danger  of  acid  poisoning  is  prevented,  and  then 
reducing  the  carbohydrate  and  protein,  or  in  a  few  cases  by 
fasting. 


32        QUESTIONS  AND  ANSWERS  FOR  DIABETICS 

21.  Question.  AVhon  the  urine  of  the  patient  is  sugar-free, 
what  is  done  next? 

Axs.  A  Httle  carbohydrate  and  protein  are  first  given  the 
patient  and  then  fat,  nieamvhile  testinji;  the  urine  daily  to 
determine  Avliether  the  total  quantity  of  food  and  the  differ- 
ent varieties  of  it  can  be  increased  without  the  return  of 
sugar  in  the  lu'ine  or  excess  of  sugar  in  the  blood. 

22.  Question.  What  can  a  diabetic  patient  do  for  himself 
besides  keeping  the  urine  sugar-free  ? 

Ans.  Be  cheerful  and  also  be  thankful  that  his  disease 
is  not  of  a  liopeless  character,  but  a  disease  which  his  brains 
will  help  him  to  conquer.  Keep  his  temper  under  control 
and  his  skin  and  teeth  scrupulously  clean.  Avoid  people 
with  head  colds  and  sore-throats.  Secure  a  daily  action  of 
the  bowels.  Sleep  nine  or  more  hours  at  night  and  invariably 
take  at  least  half  an  hour  off  for  rest  during  the  day.  Exercise 
moderately  in  the  forenoon,  afternoon  and  evening. 

23.  Question.  How  can  you  help  prevent  the  develop- 
ment of  diabetes  in  your  children  and  friends? 

Ans.  By  explaining  to  them  the  dangers  of  obesity  and 
telling  them  of  easy  ways  by  which  to  avoid  it,  such  as:  (1) 
to  leave  the  table  a  little  hungry,  (2)  to  satisfy  the  stomach 
with  unnourishing  5  per  cent,  vegetables  instead  of  with 
bread  and  butter,  which  are  fattening,  (3)  to  omit  lunches 
and  candy  and  sodas  between  meals,  (4)  to  use  skimmed 
milk  instead  of  cream.  Encourage  exercise,  abundant  sleep 
and  energetic,  yet  restful,  vacations. 

24.  Question.  Why  are  operations  often  dangerous  for 
diabetic  patients? 

Ans.     Because  of  the  possibility  of  serious  acid  poisoning. 

25.  Question.     How  can  acid  poisoning  be  prevented? 
Ans.     Practically  always  by  keeping  sugar-free.     If  the 

patient  feels  "sick"  and  is  in  doubt  about  acid  poisoning  he 
need  not  worry  if  he  (1)  goes  to  bed;  (2)  drinks  slowly  a 
cupful  of  hot  water,  tea,  coffee  or  clear  thin  broth  every  hour 


KNOWLEDGE  ESSENTIAL  FOR  A   DIABETIC         33 

or  hour  and  a  half,  or,  if  nauseated,  takes  the  same  quantity 
of  liquid  by  enema  in  the  form  of  salt  solution  (a  level  tea- 
spoonful  of  salt  to  the  pint  of  water) ;  (3)  fasts;  (4)  moves  the 
bowels  by  injection;  (5)  procures  a  nurse,  or  has  someone  to 
act  as  nurse,  so  that  he  is  relieved  of  all  responsibility  in 
carrying  out  the  above  treatment;  (6)  avoids  soda  or  other 
alkali  and  (7)  notifies  his  physician. 

26.  Question.  What  anesthetics  are  to  be  avoided  in 
case  of  a  surgical  operation? 

Ans.     Chloroform  and  ether. 

27.  Question.    What  anesthetics  may  be  safely  employed  ? 
Ans.     Novocain,  cocain,  nitrous  oxide  gas  and  oxygen, 

spinal  anesthesia. 

A  diabetic  patient  at  the  beginning  of  treatment  should  be 
made  to  understand  that  he  is  taking  a  course  in  diabetes. 

For  successful  graduation  in  the  course  he  should  demon- 
strate his  ability: 

1.  To  test  the  urine  for  sugar  (page  173). 

2.  To  serve  himself  with  approximate  accuracy,  without 
scales,  75  grams  of  a  5  per  cent,  vegetable  (pages  34-42). 

3.  To  record  a  summary  of  his  diet  for  the  previous  day 
(pages  34-42). 

4.  To  explain  the  quantity  of  carbohydrate  which  it  con- 
tains (pages  34-42). 

5.  To  state  his  diet  on  his  w^eekly  fast  day  (page  104). 

6.  To  describe  what  he  is  to  do  if  sugar  returns  in  the 
urine  (page  103). 

7.  To  describe  what  he  is  to  do  if  he  has  reason  to  believe 
that  he  is  threatened  with  acid  poisoning  (pages  32,  108). 

8.  To  know  what  to  eat  while  travelling  if  his  usual  diet 
is  not  available. 


CHAPTER   IV. 

DIABETIC  ARITILAIETIC. 

It  is  far  simpler  in  computations  of  the  diet  to  use  the 
metric  than  the  a\oir(hipois  system.  Unfortunately,  the 
more  general  employment  of  scales  registering  pounds  and 
ounces  makes  this  at  times  difficult.  For  this  reason  it  is 
well  to  know  both  the  metric  and  aA'oirdupois  systems  and 
to  be  able  to  convert  the  one  into  the  other.  The  essential 
values  are  giAen  in  Table  4. 

Table  4. — The  Metric  and  Avoirdupois  Systems  Compared 
dry  measure. 

30  grams    =    1  ounce'     '•      16  ounces    =  .1.0  pound 
1000  grams    =    1  kilogram  =   2.2  pounds 

LIQUID   MEASURE. 
30  cubic  centimeters    =    1  fluid  ounce-   :      32  ounces    =    1  quart 
1000  cubic  centimeters    =    1  liter 

CALORIES. 

1  gram  carbohydrate    =  4  calories 

1  gram  protein  =  4  calories 

1  gram  fat  =  9  calories 

The  unit  of  weight  in  the  metric  system  is  a  gram.  It  is 
easy  to  visualize  the  relative  value  of  a  gram  when  it  is  known 
that  a  nickel,  fi^'e-cent  coin,  weighs  exactly  5  grams,  a 
shredded  wheat  biscuit  weighs  30  grams,  and  so  do  three; 
large  portions  of  })iitter  or  six  of  the  large  lumps  of  sugar. 
The  average  egg  weighs  60  grams  and  a  banana  (peeled) 
100  grams.  A  kilogram  is  equivalent  to  2/2  pounds.  Kilo- 
grams become  more  homelike  when  one's  own  weight  is 
changed  into  kilograms.  Thus  a  Aveight  of  132  pounds 
avoirdupois  is  60  kilograms  metric. 

*  Actually  28 . 4  grams.  *  Actuall>-  29 .  G  grams. 

(34) 


DIABETIC  ARITHMETIC 


Fig.   1. — a,  teaspoon,  capacity  5  c.c;  b,  tablespoon,  capacity  15   c.c, 


or  5  ounce. 


a  b  c  d 

Fig.  2. — a,  cream,  5  pint  or  237  c.c;  5,  drinking  glass,  capacity  S  ounces; 

c,  250  c.c.  gi-aduate,  contains   i  pint  fluid;  d,  measuring  cup,    capacity   8 
ounces. 


36 


DIABETIC  ARITHMETIC 


The  unit  of  weight  in  Hquid  measure  in  tlie  metric  system 
is  the  cubic  centimeter.  A  cubic  centimeter  of  water 
weighs  1  gram.  Thirty  cubic  centimeters  make  a  fluid  ounce, 


-i' 

1 

^^^^^H 

^^^^^^^ 

^ 

^^m 

a  b  c  d 

Fig.  3. — a,  butter,  10  grams;  b,  shredded  wheat,  30  grams;  c,  Uneeda 
Biscuit,  6  grams;  d,  three  10-gram  weights,  total,  30  grams. 


a  b  c  d 

Fig.  4. — a,  5-gram  weight;  b,  lump  sugar,  weight,  5  grams;  c,  oyster 
crackers,  weight,  5  grams;  d,  Buffalo  5-cent  piece,  weight,  5  grams. 

which  is  approximately  equal  to  two  tablespoonfuls  of 
water.  One  thousand  cubic  centimeters  are  a  little  more 
than  a  quart. 

In  estimating  carbohydrate,  protein  and  fat  in  the  diet  or 
sugar  in  the  urine,  enough  accuracy  is  obtained  in  clinical 


DIABETIC  ARITHMETIC 


37 


work  by  considering  that  30  grams  (g.)  or  30  cubic  cen- 
timeters (c.c.)  equal  an  ounce,  dry  or  fluid  measure. 

The  foods  upon  which  diabetic  patients  live  are  nearly 
all  printed  in  Tables  5  and  6  and  are  shown  in  Fig.  6  as 
well.  Most  of  the  foods  in  Table  5  come  under  the  head 
of  5  per  cent,  vegetables.  By  this  is  meant  that  not  over 
5  per  cent,  (or  5  grams  in  each  100  grams)  of  these  vege- 
tables may  be  counted  as  carbohydrate.  As  a  matter  of  fact, 


Fig.  5. — One  teaspoonful  (5  c.c.)  of  Benedict's  solution  in  a  test-tube. 


lettuce,  at  the  beginning  of  the  first  column,  contains  2.2  per 
cent.,  and  string  beans,  tov\^ard  the  bottom  of  the  second 
column,  occasionally  contain  as  much  as  6  per  cent,  carbohy- 
drate. The  average  percentage  of  carbohydrate  for  the  entire 
group  would  be  about  3  per  cent.,  or  1  gram  carbohydrate  for 
each  (1  ounce)  30  grams  of  vegetables.  A  large  saucerful  of 
a  5  per  cent,  vegetable  weighs  about  150  grams  and  contains 
about  5  grams  of  carbohydrate.  Another  reason  for  reckon- 
ing these  vegetables  at  3  per  cent,  available  carbohydrate  is 


38 


DIABETIC  ARITHMETIC 


Table  5. — Foods  Arranged  Approximately  Accordixc  to  Content 
OF  Cahuohydratk. 

Vegetables  (fresli  or  canned). 


5  per 

cent.' 

10  per  cent.' 

15  per  cent. 

20  per  cent. 

Lettuce 

Tomatoes 

String  Iwans 

Green  peas 

Potatoes 

Cucumbers 

Brussels 

Pumpkin 

Artichokes 

Shell  beans 

Spinach 

sprouts        j 

Turnip 

Parsnips 

Baked  Ijeans 

Asparagus 

Water  cress    : 

Kohl-ral)i 

Canned            ' 

CJreen  corn 

Rhubarb 

Sea  kale 

Squash 

lima  beans 

Boiled  rice 

Endive 

Okra 

Beets 

Boiled 

Marrow 

Cauliflower 

Carrots 

macaroni 

Sorrel 

Egg  plant 

Onions 

Sauerkraut 

Cabbage 

Green  peas. 

Beet  greens 

Radishes 

canned 

Dandelion 

Leeks 

greens 

String  beans, 

Swiss  chard 

canned 

Celery 

Broccoli 

Mushrooms 

Artichokes, 
canned 

Fruits. 

Ripe  olives  (20 

per  cent,  fat) 

Watermelon 

Raspberries 

Plums 

Grape  fruit 

Strawberries 

Currants 

Bananas 

Lemons 

Apricots 

Prunes 

Cranberries 

j  Pears 

Peaches 

Apples 

Pineapple 

Huckleberries 

Blackberries 

Blueberries 

Gooseberries 

Cherries 

Oranges 

Nuts. 

Butternuts 

Brazil  nuts 

Almonds 

Peanuts 

Pignolias 

Black 

!  Walnuts 

walnuts 

(English) 

Hickory 

Beechnuts 

40  per  cent. 

Pecans 

Pistachios 

Chestnuts 

Filberts 

1  Pine  nuts 

Miscellaneous. 

Unsweetened 

and    unspiced 

pickle,  clams,  oysters,  scal- 

lops, liver,  fish  roe. 

>  Reckon  average  carbohydrates  in  a  mixture  of  vegetables  of  5  per  cent, 
group  as  3  per  cent. ;  of  10  per  cent,  group  as  6  per  cent. 


DIABETIC  ARITHMETIC  39 

that  when  they  are  cooked  considerable  carbohydrate  is  lost 
in  the  water  used  in  the  cooking.  The  same  thing  applies  to 
vegetables  in  the  10  per  cent,  column,  and  tliesc  vegetables  are 
reckoned  as  containing  6  per  cent,  carbohydrate  or  2  grams 
to  the  ounce.  In  the  15  per  cent,  and  the  20  per  cent,  vege- 
tables about  their  full  value  is  available.  Fruit,  also,  must 
be  reckoned  as  containing  the  full  quantity  of  carbohydrate 
assigned  to  it  in  the  column  in  which  it  occurs.  Patients 
seldom  need  to  know  the  food  values  of  more  than  the  21 
foods  mentioned  in  Table  6.  Patients  are  advised  to  buy 
gram  scales,  but  since  many  households  already  have  ounce 
scales,  Table  6  is  so  arranged  that  the  quantities  of  carbo- 
hydrate, protein  and  fat  in  an  ounce  (or  30  grams)  of  food 
are  placed  opposite  that  food.  There  are  a  few  exceptions. 
The  values  for  six  o^^sters  and  one  egg  are  given  instead  of 
for  30  grams  of  these  foods. 

Table  6. — The  Quantity  op  Carbohydrate,  Protein  and  Fat  and 

THE  Caloric  Value  of  Thirty  Grams  (One  Ounce)  of 

Foods  in  Common  Use.i 

30  grams  (1  ounce)  Carbohydrates,        Protein,  Fat, 

contain  approximately.  grams.  grams.  grams.        Calories. 

Oatmeal,  dry  weight         ...      20.0  5.0  2  120 

Shredded  wheat 23.0  3.0  0  105 

Cream,  40  per  cent.    ....        1.0  1.0  12  120 

Cream,  20  per  cent 1.0  1.0  6  60 

Milk 1.5  1.0                   1  20 

Brazil  nuts 2.0  5.0  20  210 

Oysters,  six      .      ' 4.0  6.0                    1  50 

Meat  (uncooked,  lean)     ...       0.0  6.0  3  50 

Meat  (cooked,  lean)  ....0.0  8.0  5  75 

Bacon 0.0  5.0  15  155 

Cheese 0.0  8.0  11  130 

Egg  (one) 0.0  6.0  6  75 

Vegetables  5  per  cent,  group      .1.0  0.5  0  6 

Vegetables  10  per  cent,  group    .2.0  0.5  0  10 

Potato 6.0  1.0  0  30 

Bread 18.0  3.0  0.5  90 

Butter 0.0  0.0  25  225 

Oil 0.0  0.0  30  270 

Fish,  cod,  haddock  (cooked)       .0.0  6.0                   0  25 

Broth 0.0  0.7                   0  3 

Fruit  10  per  cent 3.0  0.0                    0  12 

1  Convenient  food  scales  of  500  grams'  capacity  with  movable  dial  are 
made  by  John  Chatillon  &  Sons,  89  Chff  Street,  New  York  City. 


40 


DIABETIC  ARITHMETIC 


For.  another  reason,  in  the  first  Hne  the  food  vahie  of 
oatmeal  weighed  dry  is  inserted,  because  when  oatmeal  is 
cooked  the  quantity  of  water  which  it  takes  up  is  so  variable 
that  tlie  weight  of  cooked  oatmeal  would  neither  be  uniform 
from  day  to  da}'  nor  the  same  with  dilTerent  kinds  of  oatmeal, 
whereas  the  food  values  for  the  dry  weights  of  all  kinds  of 
oatmeal  remain  approximately  the  same. 

Table  7. — The  Computation  of  the  Diet. 


Food. 

Break- 
fast, 

Dinner, 

Supper, 

Total 

Carbo- 
hydrate 

Protein, 

Fat, 

grams. 

grams. 

grams. 

grams. 

Five  per  cent,  veg 

100 

+ 

200 

+ 

150 

=     450 

15 

8 

0 

Eggs  (2)    .      . 

2 

2 

12 

12 

Meat,  cooked 

()() 

=       60 

16 

10 

Fish     .      .      . 

60 

=       60 

12 

Bacon 

15 

+ 

15 

=       30 

5 

15 

Butter       .      . 

10 

+ 

10 

+ 

10 

=       30 

25 

Cream, 20  percent 

30 

+ 

30 

+ 

30 

=       90 

3 

3 

18 

Oatmeal    . 

15 

=       15 

10 

3 

1 

Totals      = 

28 

59 

81 

Calories 

per  gram      = 

4 

4 

9 

Total  calories 


112   +  236   +     729 


1077 


In  the  first  column  of  Table  7  is  recorded  a  list  of  the 
different  foods  taken  during  the  day.  Of  5  per  cent,  vege- 
tables 100  grams  were  given  for  breakfast,  200  for  dinner  and 
150  for  supper,  making  a  total  for  the  day  of  450  grams. 
Two  eggs  were  given  at  breakfast;  meat  was  given  at  dinner 
and  fish  at  supper,  but  a  little  bacon  appears  on  the  list  for 
both  breakfast  and  supper.  Cream  containing  20  per  cent, 
fat  was  given  at  each  meal;  oatmeal  only  at  breakfast. 
Knowing  the  total  quantity  of  each  kind  of  food  given 
dm*ing  the  day,  by  using  the  table  of  food  values  (Table  6) 
one  can  determine  the  amount  of  carbohydrate,  protein  and 
fat  for  each  given  food.  Thus,  450  grams  of  5  per  cent, 
vegetables  were  used.  Table  6  shows  that  for  each  30  grams 
(1  ounce)  of  5  per  cent,  vegetables  there  is  1  gram^  carbo- 
hydrate and  0.5  gram  protein,  and  therefore  in  450  grams 
(15  ounces)  there  would  be  15  grams  carbohydrate  and  half 
as  many  grams  protein,  or  8  (actually  7.5). 

1  Arithmetically,  1.5  grams,  but  on  account  of  variation  of  carbohydrate 
in  vegetables,  and  on  account  of  losses  by  cooking,  as  well  as  for  conve- 
nience, reckoned  as  1  gram. 


DIABETIC  ARITHMETIC  41 

Two  eggs  were  given  at  breakfast.  Table  6  shows  that  the 
eggs  contain  no  carbohydrate,  but  that  each  egg  contains 
6  grams  protein  and  6  grams  fat — in  other  words,  2  eggs 
contain  12  grams  protein  and  12  grams  fat.  In  the  same 
way  one  can  reckon  the  amomit  of  carbohydrate,  protein 
and  fat  in  60  grams  of  meat  (cooked),  60  grams  of  fish,  30 
grams  of  bacon,  30  grams  of  butter,  90  grams  of  20  per  cent, 
cream  (i.  e.,  cream  containing  20  per  cent,  butter  fat)  and 
15  grams  of  oatmeal.  In  Table  6  the  quantity  of  carbo- 
hydrate in  30  grams  of  oatmeal  is  given  as  20  grams — con- 
sequently in  15  grams  of  oatmeal  there  would  be  half  as 
much,  or  10  grams  carbohydrate,  3  (actually  2.5)  grams  of 
protein  and  1  gram  of  fat. 

The  actual  percentages  of  carbohydrate,  protein  and  fat 
in  various  other  foods  are  given  in  the  large  tables  on  pages 
152  to  169.  From  these  it  is  easy  to  calculate  the  quantity  of 
carbohydrate,  protein  and  fat  in  any  food  which  a  patient  takes 
when  the  total  quantity  of  food  eaten  is  known.  Patients 
and  nurses  somehow  are  repeatedly  confused  by  such  tables, 
forgetting  that  if  the  quantity  of  carbohydrate  in  milk  is 
5  per  cent.,  100  grams  of  milk  (or  in  this  case  cubic  cen- 
timeters) would  contain  5  grams  of  carbohydrate,  just  as  5 
per  cent,  interest  on  $100  for  a  year  would  be  $5.  Lobster, 
for  instance,  contains  16  per  cent,  protein,  and  therefore 
100  grams  of  lobster  contain  (100  X  0.16)  16  grams  protein. 

One  should  be  familiar  with  percentages,  because  in  this 
way  one  can  often  find  the  values  of  various  foods  which  are 
not  contained  in  the  30-gram  (1 -ounce)  table.  Should  a 
patient,  for  example,  wish  to  substitute  his  8  grams  of 
protein  in  the  form  of  30  grams  of  meat  for  8  grams  protein 
in  the  form  of  lobster,  this  could  be  done  by  his  taking 
(o"^)  50  grams  of  lobster. 

The  use  of  percentages,  however,  is  employed  far  more  in 
determining  the  quantity  of  sugar  voided  in  the  urine  by 
diabetic  patients  in  the  twenty-fom-  hom*s.  If  an  individual 
voids  2000  c.c.  (cubic  centimeters)  of  urine  and  the  per- 
centage of  sugar  is  5  per  cent.,  it  is  plain  that  the  quantity 
of  sugar  lost  in  the  urine  during  the  twenty-four  hom's  would 
be  2000  X  0.05  =  100  grams.    As  a  lump  of  sugar  amounts 


42 


DIABETIC  ARITHMETIC 


to  about  5  grams,  this  would  mean  tliat  the  equivalent  of 
20  kunps  of  sugar  was  lost  in  the  urine  in  one  day. 

It  is  interesting  to  compare  the  decrease  of  sugar  in  the 
urine  with  the  reduction  of  cai'bohydrate  in  the  diet. 

This  is  shown  in  Table  8,  which  is  far  more  simple  than 
it  appears  to  be  at  the  first  glance. 

Table  S. — Illustration  of  Ambulatory  Treatment   without 

Fasting  or  Omission  of  Protein.     Case  No.  1237.     Age 

AT  Onset  in  September,  1915,  Thirty-nine  Years 

and  Five  Months. 


Urine.  ' 

Diet 

n  grams. 

« 

■0 

s 

3 
0 

Dietary  prescriptions  in  grams. 

o 

12 
S 

Sugar. 

si 

«! 

Date, 

S 

1917. 

C) 

03 

t 

Xi 
O 

J3 

a-a 

.28 

o 
5 

3 

8 

Per 
cent. 

Total 
gins. 

o 

o 

ol  a 

-C 

a 

od 

0 
"o 

B 
0 

V 

i'g 

"o 

a 

2 

ca 

"3 

QJ-^ 

g?'" 

2 

0 

6 

al 

3 

tm     ^ 

> 

5 

U  Ip^ 

(^ 

O 

i* 

> 

E  10 

S 
"" 

^ 

± 

m 

0 

Feb.  17 

4000 

0 

8.4 

336 

1 

1 

19 

1500 

0 

2.2 

33 

54i84 

0 

720 

360  3001 

20 

1500 

0 

1.8 

27 

54  84 

0 

720 

360  300 

21 

1250 

0 

1.8 

23 

39  84 

0 

i42 

720 

360  150 

22 

1500 

0 

0.4 

6 

24  84 

0 

'432 

720 

360   0 

23 

1250 

0 

0.2 

3 

24,84 

0 

432 

720 

360   0 

24 

1500 

0 

Tr. 

0 

24  84 

0 

432 

720 

360   0 

25 

1500 

0 

Tr. 

0 

24  84 

15 

567 

i39 

720 

240 1  0 

90 

26 

0 

0 

0 

24  84 

39 

783 

720 

120   0  90 

4 

27 

1250 

0 

0 

0 

24  82 

57 

937 

720 

120   0  90 

2 

60 

Mar.  1 

0 

0 

0 

24  82 

82 

1162 

720 

120   0  90 

2 

60 

30 

3 

0 

0 

0 

26  84 

94 

1286 

138 

720 

120   0  90 

2 

60 

30 

60 

(> 

0 

0 

0 

32  85 

106 

1422 

720 

120  50  90 

2 

60 

30 

90 

9 

0 

0 

0 

42  85 

106 

1462 

136 

720 

120  150  90 

2 

60 

30 

90 

13 

.... 

0 

0 

0 

54  87 

168 

2076 

1   1 

CHAPTER  V. 
EFFICIENCY  IN  VISITS  TO  A  DOCTOR. 

A  DIABETIC  patient  frequently  fails  to  get  the  benefit  he 
should  from  a  visit  to  his  physician  because  he  does  not 
furnish  the  facts  upon  which  advice  for  further  treatment 
can  be  based.  Physical  appearance  alone  is  by  no  means 
a  sufficient  guide  to  the  careful  doctor.  Information  must 
be  presented  concerning  the  urine,  the  diet  and  often  con- 
cerning the  blood.  The  efficient  cooperation  of  the  patient 
is  necessary. 

1.  Information  Obtained  by  Examination  of  the  Urine. — The 
physician  should  know  whether  the  urine  of  the  patient  is 
free  from  sugar,  or,  if  present,  how  much  it  contains.  This  is 
essential  in  order  to  prescribe  the  diet  for  the  following  days. 
The  patient  should  therefore  take  with  him  a  specimen  of  the 
urine  saved  from  the  entire  twenty-four-hour  amount.  To 
collect  such  a  specimen  of  urine,  discard  that  voided  at 
7  A.M.  and  then  save  all  urine  passed  up  to  and  including  that 
obtained  at  7  the  next  morning.  Take  120  c.c.  (4  ounces)  of 
the  thoroughly  mixed  twenty-four  hour  quantity  for  examina- 
tion. Record  the  twenty-four  hour  amount  of  m-ine,  the  date 
and  the  name  on  the  bottle.  The  bottle  in  which  the  urine 
is  being  collected  should  be  kept  in  a  cool  place.  It  is  best  to 
procure  a  bottle^  for  this  special  purpose  sufficiently  large  to 
hold  the  entire  twenty-four  hour  amount  of  lu-ine.  Select  a 
bottle  with  a  large  mouth,  that  it  may  be  more  easily  cleansed. 
The  bottle  should  be  scalded  out  daily.  It  should  have  a 
tight-fitting  cork.  Urine  so  collected  decomposes  slowly. 
On  account  of  the  presence  of  sugar,  diabetic  urines  are  prone 
to  ferment,  and  if  fermentation  occurs  a  portion  of  the  sugar 

1  Bottles  known  to  the  druggists  as  percolator  bottles  and  graduated  in 
100  c.c.  up  to  2000  c.c.  are  most  convenient. 

(43) 


44  EFFICIENCY  IN   VISITS  TO  A   DOCTOR 

disappears  and  in^^alidates  any  subsequent  test  for  the  quan- 
tity of  sugar  wliicli  the  urine  contained  when  voided. 

From  the  diileronce  between  the  total  quantity'  of  sugar 
in  the  urine  and  the  carbohydrate  in  the  diet  it  is  possible 
to  learn  what  part  of  the  carbohydrate  of  the  diet  has  been 
assimilated  by  the  body  and  how  much  has  been  excreted 
and  so  lost.  .■\Iild  cases  of  diabetes  may  consume  in  the 
food  100  grams  of  carbohydrate  and  lose  only  10  grams  in 
the  urine;  moderately  severe  cases  may  excrete  five  times 
this  quantity,  and  very  severe  cases  will  excrete  not  only 
the  full  amount  of  carbohydrate  eaten,  but,  in  addition, 
sugar  which  tliey  have  formed  from  protein. 

2.  Information  Obtained  by  Examination  of  the  Diet. — The 
quality  and  quantity  of  the  food  eaten  during  the  twenty-four 
hoius  while  the  urine  is  being  collected  should  be  recorded.  If 
thirty  mitiutes  are  allowed  for  a  visit  to  the  physician's  office, 
it  is  no  exaggeration  to  say  that  unless  this  recording  of  the 
diet  is  neatly  done,  one-third  to  one-half  of  the  visit  is  spent 
by  the  physician  in  learning  what  the  patient  has  eaten.  For 
this  reason  patients  should  always  bring  a  diet  list  arranged 
according  to  some  such  plan  as  that  shown  in  Table  7  (page 
40). 

Even  if  the  quantities  of  carbohydrate,  protein,  fat  and 
calories  are  not  worked  out  by  the  patient,  the  grouping 
together  of  5  per  cent,  vegetables,  the  summary  of  the  total 
quantity  of  butter,  cream,  meat,  eggs,  fish,  oatmeal  and  fruit, 
rather  than  the  hit-or-miss  record  of  the  amount  taken  at 
each  meal,  saves  an  enormous  amount  of  time,  which  can  be 
far  better  employed  by  the  physician  in  giving  helpful  advice. 
In  other  words  the  patient  should  go  to  the  physician  for  treat- 
ment rather  than  for  a  lesson  in  grammar-school  arithmetic. 

3.  Information  Obtained  by  Examination  of  the  Blood. — 
Frequently  the  course  of  treatment  of  a  case  of  diabetes  is 
regulated  by  the  quantity  of  sugar  in  the  blood.  If  the 
sugar  in  the  blood  can  be  kept  at  the  normal  figure,  0.10  per 
cent.,  the  patient  is  unlikely  to  show  sugar  in  the  urine  if 
no  change  in  the  diet  is  made.  Estimations  of  blood  sugar 
are  usually  made  before  breakfast,  because  the  blood  sugar 
rises  after  meals.     Consequently,  if  the  blood  sugar  is  to 


NOTE  BOOK  45 

be  tested  it  should  be  arranged  that  this  be  done  before 
breakfast. 

4.  Body  Weight. — If  the  patient  has  scales  the  weight  fast- 
ing, and  preferably  undressed  on  the  morning  of  the  visit, 
should  be  taken. 

5.  Note  Book. — The  patient  should  have  a  note  book, 
and  show  it  to  his  physician  at  each  visit.  All  questions 
about  symptoms  and  diet  which  have  arisen  since  the 
former  visit  should  be  neatly  set  down,  with  space  left  for 
an  answer  to  each  question.  It  is  a  common  error  for 
patients  to  ask  the  same  question  many  times,  whereas  if  the 
answer  is  written  down  by  the  physician  the  question  would 
thus  be  answered  once  for  all  time.  Furthermore,  it  is  a 
great  advantage  for  a  patient  to  keep  a  note  book,  because 
gradually  it  becomes  valuable  for  reference,  and  his  whole 
plan  of  treatment  is  systematized. 

The  note  book  should  contain  a  statement  as  to  whether 
sugar  has  been  present  or  absent  in  the  urine  since  the  last 
report  to  the  physician.  Such  data  can  easily  be  gathered  on 
one  page  and  again  thus  save  time.  When  a  patient  comes  to 
my  office  with  a  single  specimen  of  urine  instead  of  a  portion 
taken  from  the  twenty-four  hour  quantity,  and  without  any 
record  of  the  food  eaten  during  the  preceding  day,  and  starts 
in  to  recount  that  he  had  nothing  but  eggs,  meat  and  fish, 
then  later  remembers  that  he  had  a  little  cream  and  various 
vegetables,  then  with  prompting  recalls  butter  and  an  orange 
and  a  little  oatmeal,  I  always  pity  him,  and  on  very  excep- 
tional occasions  am  able  to  recall  with  satisfaction  after  the 
interview  Solomon's  soliloquy  in  Proverbs  xvi,  verse  32. 


CHAPTER  VI. 
HYGIExME  FOR  THE  I)IABETI(\ 

Ani'  agency  ^vlli(•h  promotes  physical  or  mental  hygiene 
is  a  step  toward  the  pre^•ention  of  diabetes  in  the  ])re(lis- 
posed  and  the  abatement  of  its  severity  in  those  who  have 
acquired  it.  For  years  Hodgson  has  urged  in  dealing  with 
his  patients  that  they  "should  be  kept  mentally  indolent 
and  physically  active."  The  experiments  of  Cannon,  Folin 
and  their  associates  upon  the  appearance  of  sugar  in  the 
m-ine  of  animals,  and  of  both  normal  and  insane  individuals 
following  periods  of  great  emotional  excitement,  have  demon- 
strated the  truth  of  the  first  half  of  the  motto.  Therefore 
all  indi^■iduals  who  have  a  tendency  toward  diabetes  should 
be  especially  urged  to  take  vacations,  and  the  good  effect 
of  vacations  should  be  generally  pointed  out. 

Dr.  Sabine,  of  Brookline,  has  made  the  remark,  based 
upon  the  experience  of  his  long  general  practice,  that  those 
of  his  patients  who  took  active  camping  trips  in  the  woods 
bore  the  stress  of  modern  life  best.  By  this  means  exercise 
was  combined  with  mental  relaxation.  That  the  good  effects 
of  each  last  for  months  is  not  hard  to  believe.  It  is  only 
natural  to  conclude  that  if  the  muscles,  in  which  is  stored 
one-half  of  the  carbohydrate  of  the  body,  are  kept  in  good 
condition  by  training  a  favorable  effect  must  be  exercised 
upon  the  general  metabolism  of  carbohydrate.  Pedometers 
are  to  be  encoiu'aged.  It  is  better  to  discuss  liow  far  you 
have  walked  than  how  little  you  ha\'e  eaten.  Stmiulated  by 
Dr.  Allen  the  exercise  of  diabetic  patients  has  been  gradually 
increased,  except  those  unduly  weak  or  in  a  dangerous  con- 
dition upon  entrance  to  the  hospital.  The  effect  of  this 
increase  of  exercise  upon  the  well-being  of  fat  diabetics  has 
been  pronounced,  and  it  is  striking  how  many,  miles  a  semi- 
(46) 


HYGIENE  FOR   THE  DIABETIC  47 

ill  or  obese  diabetic  patient  can  learn  to  walk  during  two 
weeks.  The  patients  are  encouraged  to  take  their  walks 
soon  after  meals  and  to  go  outdoors  at  least  five  times  in 
the  day.  Not  alone  are  the  good  effects  of  exercise  shown 
by  the  freedom  of  the  urine  from  sugar  and  an  increased 
carbohydrate  tolerance,  but  by  improved  circulation  and 
general  well-being.  No  case  should  be  considered  too-  far 
advanced  for  an  attempt  at  muscular  redevelopment. 
Fasting  diabetics,  as  a  rule,  appear  to  do  better  when  up  and 
about  the  wards  for  a  few  hours  than  when  in  bed.  How- 
ever, caution  is  necessary  in  suggesting  this  plan  to  severe 
cases  of  diabetes.  Two  patients  so  weak  from  lowered 
vitality  that  they  could  not  stand,  through  the  help  of  skil- 
ful massage  and  carefully  planned  dietetic  treatment  again 
began  to  walk. 

If  the  patient,  by  means  of  exercise,  can  have  5  grams  more 
of  carbohydrate  a  day  the  added  comfort  will  be  enormous, 
for  the  addition  of  5  grams  of  carbohydrate  to  a  diet  in  a  case 
of  severe  diabetes  brings  almost  untold  joy.  It  allows  various 
alternatives,  such  as  half  a  small  orange,  70  grams  of  straw- 
berries, a  small  tablespoonful  of  cooked  oatmeal  or  a  potato 
of  the  size  of  a  pullet's  egg. 

Case  No.  1024,  a  lady,  aged  seventy-eight  years,  not 
only  took  exercise  in  the  forenoon  and  afternoon,  but  went 
out  for  her  walk  in  the  evening  with  a  flash  light. 

Case  No.  804,  a  patient  whose  diabetes  changed  from 
severe  to  moderate  and  finally  from  moderate  to  mild  under 
his  own  care  at  home,  wrote  that  he  considered  exercise  of 
the  greatest  importance.  He  said  that  he  had  the  best 
garden  of  anyone  in  his  city. 

Case  No.  352  outlived  his  expectation  of  life,  having  had 
diabetes  twenty-three  years,  and  throughout  this  time 
having  led  a  most  active  existence.     He  \\Tote: 

"First,  it  is  very  hard  to  start  the  exercise,  and  the  less 
one  feels  inclined  to  start  the  more  one  needs  it.  Second, 
it  is  neither  necessary  nor  desirable  that  it  should  be  violent. 
I  found  a  quiet  ride  of  an  hour,  walking  or  jogging  after  taking 
something  on  the  stomach,  started  up  my  old  metabolism  for 
the  whole  dav.     If  I  rode  hard  I  got  tired  out." 


4S  HYGIENE  FOR   THE  DIABETIC 

Finally,  it  is  astonishins;  how  much  exercise  a  diabetic  in 
training  can  take.  One  of  my  severe  cases,  living  on  a  strict 
diet,  several  >'ears  ago  walked  between  twenty  and  thirty 
miles  in  one  day.  Inquiry'  elicited  the  following  letter  from 
Case  No.  783,  a  HarN'ard  student,  who  frequently  shows  a 
small  trace  of  sugar,  a  case  which  borders  upon  the  renal  type 
of  diabetes.  The  blood  sugar  one  morning  before  breakfast 
was  0.07  per  cent. : 

Cambridge,  Mass.,  Dec.  1,  1915. 

"  1  first  noticed  the  efi'ect  of  exercise  last  spring.  I  was 
rowing  for  exercise  at  the  time  and  observed  that  if  I  went 
out  on  the  river  about  a  half-hour  after  lunch  and  rowed  for 
an  hour  or  less  the  test  would  not  show  any  sugar  in  the 
urine  at  any  time  during  the  afternoon,  even  though  I  ate 
potatoes  and  a  small  amount  of  bread  for  lunch.  But  if  I 
ate  potatoes  (no  bread)  without  so  exercising  the  test  always 
showed  sugar  about  two  hours  after  the  meal." 

Rest  is  essential.  A  tired  child  is  put  to  bed  and  wakens 
refreshed;  one  of  the  most  noted  surgeons  in  our  country  is 
not  ashamed  to  leave  his  guests  at  the  table  and  lie  down  for 
fifteen  minutes  after  his  luncheon;  the  best  treatment  for  a 
failing  heart  is  to  put  its  owner  in  bed  for  a  week.  Diabetic 
patients  should  rest  often,  should  never  get  tired  and  should 
avoid  athletic  contests.  The  diet  is  designed  to  give  a  rest 
to  the  pancreas.  Sleep  nine  hours  and  more  if  you  can,  and 
get  another  hour  of  rest  by  day.  Short  periods  of  complete 
relaxation  yield  maximal  returns. 

Forget  you  have  diabetes  and  do  not  talk  about  it  with 
others.  This  is  one  reason  for  not  using  saccharin,  and 
another  is  to  avoid  the  perpetuation  of  a  sweet  taste,  thus 
reviving  the  thought  of  the  previously  unrestricted  diet. 

Mental  diversion  is  desirable,  but  anxiety  is  harmful. 
Heavy  responsibilities  should  be  avoided  as  well  as  nervous 
upsets  and  emotional  excitements.  It  is  almost  as  dangerous 
for  a  diabetic  to  get  angry  as  it  is  for  a  man  with  angina 
pectoris.  Case  No.  1157  had  been  sugar-free  for  five  days, 
but  it  came  back  when  he  had  an  important  conference  with 
one  of  his  superintendents. 


HYGIENE  FOR  THE  DIABETIC  49 

Wear  warm  clothes  instead  of  staying  by  tli(3  radiator  (jr 
in  an  overheated  room. 

The  change  in  the  mental  attitude  of  patients  during  the 
course  of  treatment  is  a  gratifying  encouragement  to  the 
physician.  Untreated  diabetics  after  a  moderate  numlicr  of 
years  usually  show  depression,  and  with  women  this  often 
becomes  pronounced.  In  the  first  ten  years  of  my  experience 
with  diabetes  the  tendency  of  such  patients  to  cry  impressed 
me  greatly,  but  even  then,  with  the  methods  in  vogue,  it 
was  interesting  to  see  how  depression  disappeared  with  the 
decrease  or  disappearance  of  sugar  in  the  urine.  This  could 
not  be  explained  by  the  mental  encouragement  which  a  patient 
derived  from  his  knowledge  of  the  decrease  in  sugar  excretion. 
Even  when  patients  became  sugar-free  but  developed  acidosis, 
mental  symptoms  often  improved,  and  to  so  great  an  extent 
that  one  could  say  that  with  treatment,  even  although  it  did 
end  in  coma,  the  patient  enjoyed  life  far  more  thoroughly 
than  when  untreated.  During  the  last  five  years  the  mental 
attitude  of  the  patients  has  improved  still  more.  The  en- 
thusiasm about  new  methods  of  treatment  has  been  so  great 
as  to  account  partially  for  this;  but  the  actual  improvement 
in  health  which  the  patients  have  felt  has  been  of  more 
importance.  Greeley  explained  to  my  patients  how  diabetes 
has  largely  been  robbed  of  its  terrors.  He  urged  the  simple 
life  as  a  great  aid  in  treatment  and  told  them  not  to  try  to  be 
first  in  the  Iberian  village  and  be  ill,  but  rather  to  be  second 
in  Rome  and  keep  well.  He  told  them  to  have  a  hobby  and 
not  to  make  it  a  labor;  to  be  cheerful  and  to  keep  their  minds 
occupied,  and,  so  far  as  possible,  to  continue  the  previous 
currents  of  their  lives. 


CHAPTER  VII. 
THE  DIET  OF  NORMAL  INDIVIDUALS. 

Food  and  Fuel. — Foods  are  fuel  for  the  body,  just  as  gasoline 
is  fuel  (food)  for  an  automobile.  IMan  and  automobile 
depend  upon  fuel  as  a  source  of  energy.  In  case  the  gasoline 
gives  out  the  automobile  will  stop,  but  if  the  food  gives  out 
the  man  will  not  immediately  die,  because  he  carries  a  good 
deal  of  the  fuel  stored  up  in  his  body,  first  and  chiefly  as  fat, 
second,  a  lesser  amount  in  the  form  of  protein  in  the  muscles 
and  various  tissues,  and  third,  a  little  in  the  form  of  carbo- 
hydrate as  animal  starch  (glycogen)  and  sugar  in  the  liver, 
muscles  and  blood. 

A  fasting  man  at  the  Carnegie  Laboratory  in  Boston  went 
without  food  for  thii-ty-one  days,  living  upon  his  reserve 
supply  of  food. 

Just  as  one  can  measure  how  much  gasoline  is  required  for 
an  automobile  to  run  100  miles,  so  one  can  measure  how 
much  food  is  necessary  for  a  man  to  live  for  twenty-four 
hours  and  do  a  given  amount  of  work.  Small  automobiles 
require  less  gasoline  than  large  automobiles,  and  this  is 
pretty  much  true  of  individuals,  for  the  food  which  they  need 
depends  upon  their  weight.  There  are  exceptions.  Children 
require  proportionately  more  food  because  they  are  growing, 
and  old  people  require  less  because  they  are  quieter.  We  can- 
not measure  the  quantity  of  food  which  we  use  in  as  simple 
a  way  as  we  can  measure  the  fuel  gasoline  which  the  auto- 
mobile requires,  because  we  depend  upon  three  kinds  of  food. 
However,  it  is  obvious  that  if  the  food  value  of  1  gram  of  each 
of  the  foods,  carbohydrate,  protein  and  fat,  is  known  and 
also  the  quantity  of  each  food  which  is  eaten  the  total  food 
value  of  the  diet  for  the  patient  can  then  be  determined. 

The  nutritive  value  of  the  diet  is  readily  computed  by 
(50) 


DIET  OF  NORMAL  INDIVIDUALS 


51 


referring  to  Table  6,  page  39,  and  Fig.  6,  and  by  bearing  in  . 
mind  the  caloric  values  of  the  various  foods.    (See  page  31, 
Question  18).    Table  7,  page  40,  will  serve  as  an  example. 


5                    10                   15                   20                    25 

r30 

CALORIES 

OATMEAL 

CREAM  W/c 

CREAM  20i 

MILK 

BRAZIL  NUTS 

OYSTERS  6 

MEAT  UNCOOKED 

MEAT  COOKED 

CHEESE 

BACON 

EGG-ONE 

VEGETABLES  bf 

VEGETABLES   \0i 

POTATO 

BREAD 

BUTTER 

OIL 

COD,  HADDOCK 

BROTH 

ORANGE,  100  G.  OR 
GRAPE   FR.,  200  0. 

^^^^« 

- 

120 

120 

GO 

20 

210 

50 

50 

75 

130 

155 

75 

6 

10 

30 

90 

225 

270 

25 

3 

40 

z^ 

j    1    1    1    1    1    1    1    1    1    1 

MM 

1 

1 

1 

mm 

555? 

Z^ 

^Sl^ 

■ 

■ 

■ 

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■ 

n 

b- 

■■ 

■1 

■ 

■ 

■ 

■ 

■ 

■ 

_ 

— 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

■ 

— 

— 

-mmmm 

1 

^^^^^^^^ 

■ 

m^m^^^ 

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1            1      i  i  1 

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1       1      1      1       1       1       I       1       1       1       1       1       1       1 

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^^^^^^rt 

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b; 

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m. ii 

carbohydrate  (sugar  and  starch)^^^ 

protein  (lean  of  meat  and  eish,  curd  of  milk,  egg-white  etc.)^^^ 

fatI^^I 

Fig.  6. — Diet  table  showing  total  calories  and  quantities  in  grams  of 
carbohy(irate,  protein  and  fat  in  30  grams  (1  ounce)  of  various  foods.  Each 
lineal  division  represents  1  gram. 

The  quantity  of  food  which  an  individual  requires  has  been 
estimated  in  various  ways.  One  method  has  been  to  weigh 
the  amount  of  food  eaten  by  a  large  number  of  individuals 


Protein, 

Fat. 

grams. 

grams. 

Calories. 

185 

141 

4751 

215 

90 

3717 

224 

195 

4962 

145 

93 

3745 

130 

117 

3181 

52  DIET  OF  NORMAL  INDIVIDUALS 

and  then  calculate  the  amount  consumed  by  each  individual. 
The  accuracy  of  such  a  method  depends  upon  many  factors, 
and  obviously  a  man's  allowance  of  food  should  not  be  com- 
pared with  his  actual  consumption  of  food.  Soldiers  are 
assigned  rations,  but  it  is  improbable  that  they  eat  what  they 
are  allowed.  A  comparison  of  the  French  and  American 
rations  is  significant.  The  rations  furnished  soldiers  in 
various  armies  are  reported  to  be  as  shown  in  Table  1). 

Table  9. — Soldiers'  Rations. 

Carbo- 
hydrate, 
grams. 

United  States  garrison  ration     .  651 

Russian  ration  in  Manchurian  war  487 

British  ration 524 

Italian  ration         560 

French  ration  (.normal)    ....  402 

Another  methotl  allows  the  food  required  by  a  given  indi- 
vidual to  be  calculated  far  more  accurately.  By  this  method 
the  total  heat  given  ott'  by  a  man  at  rest  or  at  work  has  been 
measured. 

This  total  heat  represents  energy  which  has  been  derived 
rom  the  oxidation  of  the  three  foodstufls — carbohydrate, 
protein  and  fat.  It  is  unessential  whether  the  foodstuffs 
oxidized  have  been  taken  within  a  few  moments  as  food  or 
whether  they  represent  food  deposited  in  the  body  as  fat 
(fat  tissue),  protein  (muscle  tissue)  or  carbohydrate  (glyco- 
gen, i.  e.,  animal  starch).  Knowing  the  total  heat  given  off 
it  is  not  a  difficult  matter  to  calculate  how  much  carbohy- 
drate, protein  and  fat  would  be  required  to  produce  it. 

Experiments  have  demonstrated  that  the  heat  which  is 
liberated  in  the  body  from  the  coml)ustion  of  1  gram  of 
protein  or  of  carbohydrate  produces  4  calories,  from  1  gram 
of  fat  9  calories  and  from  1  gram  of  alcohol  7  calories.  Fat, 
as  would  be  expected  is  more  than  twice  as  nourishing  as 
carbohydrate  or  protein.  With  these  figures  in  mind  it  is  easy 
to  estimate  with  sufficient  exactness  from  dietetic  tables  the 
calories  in  the  diet  required  to  replace  the  heat  given  off  by 
the  body  during  the  period  of  the  experiment.  The  result 
of  such  calculations  is  embodied  in  what  follows. 


DIET  OF  NORMAL  INDIVIDUALS  53 

Individuals  with  sedentary  occupations  require  approxi- 
mately 30  calories  per  kilogram  body  weight.  Thus  a  man 
weighing  70  kilograms,  or  154  pounds  (1  kilogram  =  2.2 
pounds),  would  need  2100  (70  x  30)  calories.  The  caloric 
needs  of  the  body,  however,  vary  not  only  from  day  to  day 
but  from  moment  to  moment.  Thus  an  individual  lying 
down  requires  not  over  25  calories  per  kilogram  body  weight, 
but  at  moderate  work  30  or  more.  So  much  of  the  twenty- 
four  hours  is  spent  sleeping  that  the  individual  saves  then 
what  he  uses  at  other  periods.  To  walk  one  hour  on  a  level 
road  at  the  rate  of  2.7  miles  an  hour  requires  160  calories 
above  that  of  keeping  quiet  according  to  Lusk.  For  a  man 
to  ascend  a  flight  of  stairs  ten  feet  high  about  3  calories  are 
necessary.  Table  10  shows  the  calories  needed  according  to 
the  amount  of  work  done. 

Table   10.  —  Calories  Required  during  Twenty-four  Hours  by 
AN  Adult  Weighing  Seventy  Kilograms  (One  Hundred 
AND  Fifty-four  Pounds). 


Condition. 

Calories  per 

kilogram,  body 

weight. 

Calories  per 
pound, body 

weight. 

Total  calories. 

At  rest 

At  light  work 

At  moderate  work 

At  hard  work 

.     25  to  30 
.     35  to  40 
.     40  to  45 
.     45  to  60 

11  to  14 
16  to  18 
18  to  20 
20  to  27 

1750  to  2100 
2450  to  2800 
2800  to  3150 
3150  to  4200 

Children  require  far  more  food  than  adults,  because  of 
growth  and  increased  activity.    This  is  shown  in  Table  11. 

Table  11. — Caloric  Needs  of  Children  during  Twenty-four 

Hours. 


Age  in  years. 

kg. 

W 

eight: 

pounds. 

Calories  per 

kilogram, 
body  weight. 

Calories  per 

pound, 
body  weight. 

Total 
calories. 

2 

12 

26 

80 

36 

960 

6 

20 

44 

70 

31 

1400 

12 

36 

80 

50 

23 

1800 

Composition  of  the  Normal  Diet. — The  ordinary  diet  for  a 
man  at  moderate  physical  work  would  contain  about  400 
grams  of  carbohydrate,  100  grams  of  protein  and  100  grams 
of  fat.  This  would  amount  to  2900  calories  in  the  twenty- 
four  hours,  or  about  40  calories  per  kilo  for  an  individual 


Calories, 

Total 

per  gram. 

calories. 

4 

1600 

4 

400 

9 

900 

54  DIET  OF  NORMAL  INDIVIDUALS 

weighing  70  kilograms  (154  pounds).  These  figures  would 
be  proportionately  reduced  both  for  those  of  lower  body 
weight  and  for  those  with  lighter  occupations  who  would 
require  nearer  oO  calories  per  kilo.  As  age  advances  the 
metabolic  requirements  are  lessened;  thus  if  2000  calories  are 
required  at  thirty  years,  1800  calories  will  suffice  at  seventy 
and  1{)00  at  eighty  years  of  age.  An  individual  weighing 
4.")  kilograms  (91)  pounds)  could  get  along  very  comfortably 
in  old  age  on  1000  calories  a  day. 

Table  12. — The  Carbohydr.\te,  Protein  and  Fat  in  the  Diet  of 

A  Man  doing  Moderate  Work,  Weight  70  Kilograms 

(154  Pounds). 

Quantity, 
Food.  grams. 

Carbohydrate     ....     400 

Protein 100 

Fat 100 

2900 

Chittenden,  in  his  painstaking  and  scientific  manner, 
accomplished  an  immense  amount  of  good  when  he  showed 
that  people  ordinarily  consumed  much  more  food  than 
physiological  needs  demand.  He  suggests  that  it  is  more 
than  probable  that  this  excess  of  food  is,  in  the  long  run, 
detrimental  to  health,  weakening  rather  than  strengthening 
the  body  and  defeating  the  very  object  of  nutrition. 

From  the  preceding  statements  it  will  be  seen  that  more 
than  half  (55  per  cent.)  of  the  energy  of  the  diet  of  the  normal 
individual  consists  of  carbohydrate.  These  figures  are  only 
approximate,  but  they  leave  no  doubt  as  to  how^  large  a  place 
sugar  and  starch  occupy  in  the  daily  ration.  Fig.  7,  page  55, 
shows  graphically  the  relative  caloric  value  of  the  dift'erent 
foodstuff's  in  the  total  diet. 

The  quantity  of  protein  in  the  normal  diet  is  probably 
decidedly  less  than  100  grams.  From  Cannon's  investi- 
gations at  the  FTarvard  Medical  School  it  would  appear 
that  hardworking  medical  students,  \vith  their  regular 
activities,  eat  about  90  grams  each  day.  There  is  compara- 
tively little  doubt  but  that  it  is  safe  for  an  individual  to  get 


DIET  OF  NORMAL  INDIVIDUALS 


55 


along  on  1  gram  protein  per  day  for  each  kilogram  body 
weight,  and  a  doctor's  worry  ends  if  his  patients  secure  60 
grams  protein,  even  though  the  students  ate  rather  more. 
Protein  is  animal  food  to  a  large  degree;  hence  its  cost.  This 
is  an  added  reason  for  being  sparing  in  the  use  of  protein. 
There  is  also  still  another  reason,  for  when  an  excess  of 
protein  is  burned  the  other  foods  are  also  consumed  more 
rapidly,  and  there  is  more  chance  for  the  heat  so  produced 
to  go  to  waste. 


400  G.    CArtB 
1600  CALS. 


100  0.    FAT 
900  CALS. 


100  G.  PROTEir 


Fig,  7. — The  relative  caloric  value  of  protein,  carbohydrate  and  fat 
in  a  normal  diet. 


The  quantity  of  fat  in  the  normal  diet  varies  partly  from 
choice  and  partly  from  economic  reasons.  In  general  in 
those  cases  in  which  the  carbohydrate  in  the  diet  is  high  the 
fat  is  low,  and  vice  versa.  The  Voit  standard  placed  the  fat 
at  55  grams,  but  in  a  series  of  1300  dietary  studies  of  families, 
carried  out  among  different  races  and  in  different  countries, 
it  was  shown  that  the  average  quantity  of  fat  eaten  was 
about  135  grams  (4.5  ounces)  per  person  per  day,  the  varia- 
tion recorded  being  from  45  to  390  grams  per  person  per  day. 

The  more  agreeable  varieties  of  fat,  such  as  butter,  cream 
and  oil,  are  expensive  foods.  Fat  is  also  a  concentrated  food, 
not  only  because  it  has  twice  the  caloric  value  of  either 
carbohydrate  or  protein,  but  because  it  occurs  more  fre- 
quently in  pure  form.  Oil,  butter  and  lard  contain  little 
water,  whereas  except  for  pure  sugar  and  starch  most  car- 
bohydrates and  proteins  are  diluted  five  to  ten  times  with 
water. 

The  chief  source  of  error  in  calculating  the  total  caloric 
value  of  the  diet,  and  especially  of  the  diabetic  diet,  is  in  the 
estimation  of  fat.     Anyone  can  realize  this  upon  examining 


56  DIET  OF  NORMAL  JXDIVJDUALS 

a  piece  of  meat  with  its  fringe  of  fat.  Tlie  fat  in  bacon  is 
most  variable,  and  in  amount  its  ^'alue  can  only  be  approxi- 
mately estimated.  Portions  of  bacon  lose  from  43  to  ()7  per 
cent,  of  fat  in  the  cooking.  For  this  reason  some  physicians 
prefer  to  have  the  allowance  of  bacon  for  their  patients 
weighed  imcooked  and  then  the  fat  which  escapes  in  the 
])rocess  of  cooking  can  be  utilized  in  the  prejiaration  of  their 
other  food.  As  the  proportion  of  i)rotein  to  fat  in  dilVerent 
samples  of  bacon  varies  considerably  the  inconvenience  of 
Avcighing  the  bacon  uncooked  has  hardly  seemed  to  me  to 
counterbalance  the  questionable  gain  in  accuracy.  For  this 
reason  my  patients  weigh  their  bacon  after  it  is  cooked. 

Fggs  in  some  cities  by  law  must  weigh  a  pound  and  a  half 
a  dozen,  an  average  of  60  grams  (2  ounces)  apiece.  Such 
eggs  contain  approximately  6  grams  of  protein  and  6  grams  of 
fat.  How  gross  om*  caloric  reckonings  are  is  obvious  if  a 
collection  of  eggs  is  weighed  and  the  minimmn  and  maxummi 
weights  noted.  The  weight  of  the  hea\iest  egg  in  a  collection 
of  56  eggs  was  72  per  cent,  more  than  that  of  the  lightest. 
The  0  grams  of  protein  are  equally  diA'ided  between  the  white 
and  the  yolk,  but  the  6  grams  of  fat  are  all  in  the  yolk. 
"When  protein  without  fat  is  desired  in  the  diet  one  whole 
egg  and  the  whites  of  two  others  can  be  made  into  a  dish  of 
scrambled  eggs.  This  would  contain  protein  12  grams  and 
fat  3  grams. 

The  weight  of  one  egg  shell  is  usually  about  7  gi-ams. 

Milk  may  be  employed  in  the  treatment  of  diabetes,  but 
it  must  be  prescribed  and  taken  with  care,  because  of  the 
large  quantity  of  carbohydrate,  protein  and  fat  which  it 
contains.  A  glass  of  milk  is  drunk  so  easily  that  one  is  apt 
to  forget  that  it  contains  12  grams  carbohydrate,  8  grams 
protein  and  8  grams  fat.  Fig.  8,  page  57,  makes  this  clear. 
Skimmed  milk  and  buttermilk  contain  the  same  quantity  of 
carbohydrate  and  protein  as  whole  milk,  but  difl'er  from  it  in 
the  absence  of  fat.  Thirty  c.c.  (1  ounce)  of  skimmed  milk, 
whole  milk  or  l)uttermilk  contain  1.5  grams  of  car])()hydrate 
and  1  gram  of  protein,  and  1  quart  of  skimmed  milk  contains 
approximately  48  grams  carbohydrate  and  32  grams  protein. 
^^'hey  contains  5  i)er  cent,  carbohydrate,  but  practically  no 


DIET  OF  NORMAL  INDIVIDUALS 


57 


protein  or  fat.  Cream  and  koumiss  contain  about  3  per  cent, 
carbohydrate,  or  1  gram  to  the  ounce. 

Diabetic  patients  seldom  become  sugar-free  on  a  milk 
diet.  They  may  become  sugar-free  if  so  little  milk  is  taken 
that  the  patient  is  partially  fasting. 

The  high  nutritive  value  of  cream,  butter  and  cheese  is 
evident  from  Fig.  8.  This  makes  these  special  milk  products 
desirable,  but  if  carelessly  taken,  danger  of  acid  ]>oisoning 
arises  from  the  large  amount  of  fat  which  they  contain.  The 
high  protein  value  of  milk — 1  gram  to  .the  ounce,  32  grams 
to  the  quart — is  important  to  consider,  not  alone  because 


QUANTITY 

(30   GRAMS 
OR    1  OUNCe) 

PS;   <]=CARB.                  ^^^=  PROTEIN                              ^H  =  FAT 

5                   10                  15                   20                  25                  30 

TOTAL 
CALORIES 

SKIMMED  MILK 
MILK 

CREAM  207, 
CREAM  Wk 
BUTTERMILK 
BUTTER 
WHEY 
CHEESE 

s^-" 

1 

^ 

1  1 

10 

1 

20 

>Ss- 

sl 

^ 

_■ 

60 

^ 

n 

5S: 

— 

— 

~^~ 

— 

■ 

■ 

_ 

— 

— 

_ 

— 

_ 

_ 

_ 

_ 

SSS 

— 

W, 

-1 

■ 

■ 

■ 

■ 

1 

— 

— 

-^ 

— 

— 

— 

10 

?^ 

^ 

W 

i 

I 

1 

1 

.^ 

1 

1 

a. 

1 

ri 

.      1 

i. 

■ 

ri 

1 

1 

■ 

1 

1 

225 

i   V 

1 

■ 

^ 

§1 

\ 

- 

- 

- 

ifffm 

I 

1 

1 

d 

1 

■ 

1 

1 

1 

1 

1 

1 

- 

_ 

_ 

- 

- 

130 

Fig.  8. — Milk  and  milk  products.     Carbohydrate,  protein  and  fat  in 
30  grams,  or  1  ounce.     Each  lineal  di\'ision  represents  1  gram. 


of  the  protein  itself,  but  also  because  from  protein  sugar  is 
often  formed.  Cheese  contains  about  half  again  as  much 
protein  as  fish. 

Repeatedly  physicians  and  patients  have  requested  me 
to  arrange  the  common  articles  of  the  diabetic  diet  men- 
tioned in  Table  6  in  terms  of  household  measure.  To  a 
considerable  extent  this  is  impracticable,  because  the  diabetic 
diet  deals  with  so  small  a  quantity  of  carbohydrate.  For 
this  reason  the  only  safe  way  for  diabetic  patients  at  the 
commencement  of  their  training  is  to  weigh  theii*  food. 
After  a  few  days  of  weighing,  patients  can  select  utensils 


58  DIET  OF  NORMAL  INDIVIDUALS 

from  their  own  pantry  or  china-closet  which  conform  to  the 
size  of  the  portions  of  their  own  special  diets  and  use  these 
exclusively.  By  this  means  needless  weigliing  is  avoided. 
Two  such  utensils  are  shown  in  Fig.  9. 

The  ramekin  level  full  of  Quaker  Oats  holds  30  grams. 
When  packed  tightly  with  5  per  cent.  N'egetables  or  potato 
it  holds  90  grams,  but  when  filled  loosely  in  the  ordinary 
manner,  75  grains.  The  pitcher  holds  60  c.c,  or  2  ounces, 
and  is  graduated  to  15  c.c. 


a  b 

Fig.  9. — a,  a  ramekin  this  size  holds  45  c.c.  of  water,  or  3  tablespoonfuls; 

b,  a  pitcher  graduated  to  15  cc^;  capacity,  60  c.c. 

Patients  and  physicians  often  err  in  thinking  their  com- 
putations of  the  diet  are  extremely  acciu-ate.  In  order  to 
demonstrate  the  errors  which  easily  arise  from  general 
statements  about  foods.  Fig.  10,  page  59,  is  inserted. 

It  is  manifestly  inaccurate  to  allow  one  orange  in  lieu  of 
10  grams  carbohydrate,  for,  as  the  illustration  shows,  three 
oranges  may  contain  respectively  10,  15  or  20  grams  carbo- 
hydrate. 

Similar  wide  variation  in  carbohydrate  content  occurs  in 
grape  fruit.  The  oranges  from  left  to  right  are  sold  under  the 
trade  names  of  126,  170  and  250  (to  the  box)  and  the  grape 
fruit  under  the  trade  names  of  28,  64  and  96  (to  the  box). 
At  the  New  England  Deaconess  and  Corey  Hill  Hospitals 


DIET  OF  NORMAL  INDIVIDUALS 


59 


oranges  and  grape  fruit  are  now  prescribed  according  to 
the  weight  of  the  peeled  pulp.  Errors  in  eggs  may  compen- 
sate themselves,  because  the  eggs  average  about  GO  grams. 
Potatoes  vary  enormously  in  size,  the  diagram  of  the  smallest 


Fig.  10. — Variations  in  the  sizes  of  common  foods.     C.  =  carbohydrate; 
P.  =  protein;  F.  =  fat. 


.60  DIET  OF  NORMAL  IXDIVIDUALS 

shown  here  is  in  reality  the  size  of  an  egu".    It  is  i(uite  unsafe 
to  guess  at  the  size  of  a  potato. 

It  is  partly  on  accoinit  of  the  ease  with  which  large  errors 
in  the  carbohydrate  content  of  food  may  occur  that  it  is 
desii-able  to  gi\e  to  patients  witli  a  low  carbohydrate  toler- 
ance their  carbohydrate  in  the  form  of  5  per  cent,  vegetables 
exclusively,  for  an  error  in  weight,  reaching  120  grams  (4 
ounces)  could  not  exceed  4  grams  of  carbohydrate. 


CHAPTER  VIII. 

THE  DIET  OF  DIABETIC  INDIVIDUALS. 

The  Normal  and  Diabetic  Diets  Compared. — Four-sevenths 
of  the  calories  of  the  diet  in  health  are  made  up  of  carbo- 
hydrate, two-sevenths  of  fat  and  one-seventh  of  protein;  but 
in  diabetes  the  diet  is  composed  almost  exclusively  of  the 
latter  two  foods.  This  is  not  discouraging,  for  until  recently 
the  Eskimo's  diet  contained  only  about  one-seventh  carbo- 
hydrate. It  takes  time  and  experience  to  learn  to  live  suc- 
cessfully upon  a  diabetic  diet,  and  it  is  only  with  time  that 
the  body  adjusts  itself  to  a  diet  with  so  marked  a  reduc- 
tion of  carbohydrate  and  so  marked  an  increase  in'  fat.  It  is 
indeed  wonderful  that  it  is  possible  for  the  body  to  do  so  at  all. 


CARBOHYDRATE 
PROTEIN 

NORMAL 

DIABETIC                     1 

;  -t'  r    ;    !    jH 

V^ 

^ 

^ 

^ 

^ 

^2 

50   r,. 

^  \  m 

76   G. 

; 

^^|0C. 

^^^^^ 

^90   C 

. 

11  1  1  1 

1    1    1 

1 

FAT 

^^65  g;. 



_ 

_ 

_ 

_ 

L 

■■■■n 

10_ 

£ij 

L 

_ 

Fig.  11. — The  diet  of  a  normal  and  of  a  diabetic  individual  compared. 
Weight  of  each  patient  60  kilograms  (60  X  2.2  =  132  pounds).  Foods 
arranged  in  grams. 


Fig.  12. — Foods  arranged  in  calories.     Sanie  as  Fig.  11. 

In  Figs.  11  and  12  the  carbohydrate,  protein  and  fat  in  the 
normal  and  diabetic  diets  are  graphically  compared  by  weight 
and  by  calories.     It  is  assumed  in  this   comparison  that  a 

(61) 


62  DIET  OF  DIABETIC  INDIVIDUALS 

diabetic  patient  has  a  tolerance  for  75  grams  carbohydrate. 
It  will  be  noted  that  the  total  caloric  value  of  the  diabetic 
diet  is  slightly  less  than  the  normal  diet.  This  is  so  arranged 
with  design,  partly  because  the  diabetic  patient  is  usually 
less  active  and  partly  because,  by  a  slight  restriction  of  diet, 
the  opportunity  for  improvement  of  the  diabetes  is  favored. 
Caloric  Needs  of  the  Diabetic. — The  diet  of  the  diabetic 
patient  should  contain,  except  for  brief  intervals,  the  mini- 
mum number  of  calories  which  the  normal  individual  would 
requhe  under  similar  conditions.  Many  normal  individuals, 
in  my  opinion,  actually  live  upon  less  than  30  calories  per 
kilogram  body  weight,  and  repeatedly  one  sees  diabetic 
patients  over  fifty  years  of  age  who  comfortably  live  upon 
less  for  long  periods.  This  is  true  only  for  the  treated 
diabetic.  If  the  patient  is  allowed  more  than  the  minimum 
amount  of  food  there  is  far  more  likelihood  that  a  portion 
will  be  unassimilated  and  appear  as  sugar  in  the  urine.  One 
of  the  first  rules  for  the  diabetic  patient  to  learn  is  never  to 
overeat.  He  should  be  a  model  in  food  conservation  for 
his  household.  As  a  matter  of  fact  during  scientific  treatment, 
he  always  returns  a  clean  plate  because  his  appetite  is  always 
equal  to  the  food  allowed. 

Table  13. — The  Effect  of  the  Restriction  of  Food  upon 
Diabetic  Mortality. 

Berlin. 

1913 409 

1914 467 

1915 383 

1916 331 

1917 264 

1918 177 

The  beneficial  effects  of  a  low  diet  upon  diabetic  patients 
were  repeatedly  observed  in  Germany  during  the  years  1914 
to  1918.  This  is  well  shown  in  a  paper  by  Rosenfeld,  of 
Breslau,  from  which  Table  13  is  constructed.  Even  in  the 
United  States  the  census  reports  for  1916  and  1917  show  for 
almost  the  first  time  in  a  generation  a  halt,  and  in  fact  even 
a  decline,  in  the  mounting  death-rate  from  diabetes  (see 
Chart,  page  26).     With  the  resumption  of  abundant  food  it 


Munich. 

Breslau. 

105 

100 

104 

115 

101 

113 

82 

78 

73 

72 

77 

51 

CARBOHYDRATE  IN  VEGETABLES  63 

is  probable  that  the  frequency  and  unfortunately  the  mor- 
tality of  diabetes  will  again  increase.  What  effect  the  diminu- 
tion in  the  supply  of  alcohol  and  the  coincident  increase  in 
the  consumption  of  candy  will  exercise  upon  diabetic  statis- 
tics is  problematical.  Very  likely  it  will  be  eventually 
possible  to  determine  whether  the  calories  omitted  as  alcohol 
are  offset  by  the  addition  of  sugar. 

Carbohydrate  in  the  Diabetic  Diet. — The  total  carbohy- 
drate in  the  diet  of  diabetic  patients  is  almost  invariably 
restricted  and  seldom  exceeds  100  grams.  This  is  a  decrease 
to  approximately  25  per  cent,  of  the  normal  carbohydrate 
ration.  It  so  radically  changes  the  composition  of  the 
normal  diet  as  to  make  it  self-evident  that  rapid  changes 
from  a  normal  to  a  diabetic  diet  containing  even  100  grams 
carbohydrate  might  easily  cause  indigestion  in  normal  as 
well  as  in  diabetic  individuals.  The  decrease  in  carbo- 
hydrate must  be  eventually  compensated  by  an  increase 
in  fat. 

The  Estimation  of  the  Carbohydrate  in  the  Diabetic  Diet. — 
The  quantity  of  carbohydrate  in  various  foods  is  easily  cal- 
culated and  far  more  simply  than  is  usually  thought.  (See 
Table  6,  p.  39,  with  accompanying  text.) 

Carbohydrate  in  Vegetables. — It  would  appear  time-con- 
suming to  determine  the  amount  of  carbohydrate  in  the 
various  vegetables  W'hich  the  patient  eats  in  twenty-four 
hours,  and  this  is  actually  the  case.  Fortunately  the 
content  of  carbohydrate  in  the  5  and  10  per  cent,  groups 
of  vegetables  is  so  small  that  one  is  justified  in  the  vast 
majority  of  cases  in  accepting  an  average  figure  for  the 
group.  It  is  true  that  there  is  considerable  variation  in 
each  group  in  Table  5,  but  the  average  content  is  not  far 
from  that  represented,  the  error  being  on  the  lower  side. 
This  does  not  hold  for  string  beans,  because  often  trouble 
occurs  from  the  beans  having  developed  into  maturit}^, 
thus  greatly  increasing  their  content  in  carbohydrate. 
Many  an  unexplained  trace  of  sugar  in  the  urine  has 
undoubtedly  occurred  in  this  way.  "Refugee"  beans  are  an 
excellent  variety.  "Kentucky  Wonder"  beans  are  also  highly 
recommended  for  the  garden,  because  they  last  so  long. 


64  DIET  OF  DIABETIC   INDIVIDUALS 

One  will  not  be  very  wrong  if  he  considers  the  maximum 
amount  of  carbohydrate  wliich  a  diabetic  will  secure  from 
.1  jier  cent,  vegctablos  in  the  twenty-four  hours  as  20  grams. 
Tliis  is  why  in  mild  cases  of  diabetes  it  is  unnecessary  to 
weigh  the  vegetables,  for  it  is  improbable  that  a  patient 
will  eat  too  much  of  these.  Even  a  moderately  severe 
diabetic  can  partake  very  freely  of  these,  and  particularly 
is  it  the  case  when  those  selected  are  lettuce,  cucumbers, 
spinach,  as])aragus,  rhubarl),  cndi^■c  and  Acgctablc  marrow. 

Loss  of  Carbohydrate  in  Cooking  Vegetables. — The  longing 
for  carbohydrates  is  occasionally  relieved  by  giving  patients 
food  which  simulates  carbohydrate,  yet  in  reality  is  free 
from  it.  Foods  of  this  type  are  free  from  carbohydrate  and 
fat  and  contain  a  negligible  amount  of  protein.  Washed 
vegetables  constitute  a  food  of  this  type.  Vegetables  lose 
carbohydrate  in  the  cooking,  and  this  loss  is  favored  (1)  by 
changing  two  or  three  times  the  water  in  which  they  are 
prepared;  (2)  by  preparing  the  vegetables  in  finely  di^•ided 
form  so  that  the  water  can  have  easy  access  to  the  whole 
mass  and  thus  dissolve  out  the  carbohydrate. 

Von  Xoorden^  pointed  out  that  100  grams  of  raw  spinach 
contained  2.97  grams  carbohydrate,  but  cooked  spinach 
only  0.85  gram.  Similarly  100  grams  of  ripe  peaches  con- 
tained 9.5  grams  carbohydrate,  but  when  boiled  and  the 
water  changed,  only  l.S  grams.  Allen-  has  utilized  this 
method  of  removing  carbohydrate  from  vegetables,  and 
thus  allows  patients  to  have  bulk  in  their  diet.  He  terms 
vegetables  so  prepared  "  thrice-cooked"  vegetables.  "  Under 
these  conditions  the  ^■egetables  may  be  boiled  through 
three  waters,  throwing  away  all  the  water.  Nearly  all 
starch  is  thus  removed.  The  most  severe  cases  generally 
take  these  thrice-cooked  \egetables  gladly  and  without 
glycosuria."  Patients  often  say  that  it  makes  little  differ- 
ence to  them  whether  the  vegetables  are  thrice  washed  or 
not.  It  is  easy  and  useful  to  add  a  little  salt,  and  if  desired 
the  vegetables  can  be  fla\'()red  with  meat  juices  or  meat 
extracts.     The   vegetables   which    most    readily   ])art   Avith 

'Von  Noorden:     Die  Zuekerkiankheit,  Berlin,  1912,  p.  30G, 
*  Allen:     Boston  Med.  and  Surg.  .Jour.,  1915,  clxxii,  241. 


THE  CARBOHYDRATE  IN   VARIOUS  FOODS  0,', 

their  car})ohydrates  are  spinach,  celery  and  ca}>})age. 
Canned  asparagus  and  canned  spinach,  carrots  and  rhubarb 
should  be  washed  six  times.  The  carbohydrate  in  cauli- 
flower is  removed  with  great  difficulty  and  this  vegetable 
had  best  not  be  used  for  this  purpose.  Professor  Wardall 
reports  that  three  washings  will  remove  the  carbohydrate 
from  beets  and  seven  washings  that  from  parsnips.  Pre- 
sumably this  is  due  to  the  carbohydrate  in  these  vegetables 
being  more  largely  in  the  form  of  soluble  sugar  than  in  that 
of  the  relatively  insoluble  starch. 

The  Carbohydrate  in  Various  Foods.  —  1.  Potatoes. — The 
variation  in  the  percentage  of  carbohydrate  in  potatoes 
before  and  after  cooking  is  negligible,  save  with  potato 
chips,  in  which  on  account  of  the  loss  of  water  in  their 
preparation  the  carbohydrate  is  more  than  doubled. 
Emphasis  should  be  laid  upon  the  comparatively  small 
amount  of  carbohydrate  in  potato  in  proportion  to  its  bulk 
in  comparison  with  the  large  percentage  of  carbohydrate 
in  bread.  A  considerable  number  of  my  milder  cases  of 
diabetes,  by  giving  up  bread  and  bread  preparations  entirely, 
have  been  able  to  eat  potatoes  freely.  In  prescribing 
potatoes  for  diabetic  patients  it  is  desirable  to  designate 
baked  potatoes.  These  can  be  eaten  agreeably  together 
with  the  skins  when  they  have  been  carefully  cleaned  with 
a  scrubbing  brush  in  the  kitchen.  Baked  potatoes  are 
advantageous  in  two  wa^^s:  the  skins  are  quite  an  addition 
to  the  meager  diet  of  the  diabetic,  and,  furthermore,  they 
counteract  constipation. 

2.  Nuts. — ^Nuts  containing  15  and  20  per  cent,  carbo- 
hydrate are  probably  far  less  objectionable  than  most  other 
foods  with  a  similar  carbohydrate  content.  This  is  due  to 
the  fact  that  in  such  nuts  as  almonds  and  peanuts  a  larger 
part  of  the  carbohydrate  is  in  the  form  of  pentosan,  galactan 
or  other  hemicelluloses,  which  probably  do  not  readily  form 
sugar.     There  is  a  field  for  investigation  open  here. 

3.  Fruit. — Fruit  is  most  desirable  for  a  diabetic  patient  if 
his  tolerance  will  allow  him  to  take  it.  The  taste  is  agree- 
able, it  serves  instead  of  a  dessert  and  so  relieves  the  patient 
of  the  embarrassment  of  sitting  idly  at  the  table  when  others 

5 


66  DIET  OF  DIABETIC  INDIVIDUALS 

are  .eating.  The  best  varieties  of  fruit  for  diabetic  patients 
are  grape  fruit  (5  per  cent.),  strawberries  (7  per  cent.)  and 
oranges  (11  per  cent.).  These  fruits  are  safer  for  the 
patient  than  apples  (15  per  cent.),  because  they  contain  5 
to  10  per  cent,  k^ss  carbohydrate,  and  are  more  satisfying. 
Furthermore,  it  is  less  easy  thoughtlessly  to  eat  an  orange 
than  an  apple  and  thus  break  dietetic  restrictions. 

At  present  my  patients  use  the  following  equivalents  in 
their  choice  of  fruits  as  representing  10  grams  carbohydrate 
(Table  14). 

Table  14. — Equivalents  of  10  Grams  Carbohydrate  in 
Various  Fruits. 

Grams. 

Orange  pulp 100 

Grape  fruit  pulp 200 

Strawberries 150 

Blackberries 100 

Raspberries 75 

Peaches 75 

Blueberries 65 

Banana 50 

4.  The  quantity  of  carbohydrate  in  a  very  small  orange 
is  about  10  grams.  The  same  statement  will  apply  to  one- 
half  a  small-sized  grape  fruit.  One  will  not  be  far  wrong 
to  consider  that  one  compartment  of  a  very  small  orange 
contains  1  gram  carbohydrate.  The  illustration  on  p.  59 
shows  that  larger  oranges  and  larger  grape  fruit  easily  con- 
tain twice  as  much  carbohydrate  as  do  the  smaller  varieties. 

5.  Bananas. — Bananas  can  seldom  be  taken  by  diabetic 
patients  because  the  content  of  carbohydrate  is  so  high,  being 
equivalent  to  that  in  potato.  In  general  the  riper  a  banana, 
and  for  that  matter  any  vegetable  or  fruit,  the  more  starch 
in  it  has  changed  to  sugar;  and  also  the  more  carbohydrate 
it  contains.  Since  unripened  fruits  with  their  lower  car- 
bohydrate content  can  be  made  palatable  by  cooking,  a 
way  is  afforded  for  diabetic  patients  to  use  them. 

6.  Ripe  Olives. — Ripe  olives  make  a  pleasing  change  in 
the  diet.  They  contain  4  per  cent,  carbohydrate  in  con- 
trast to  green  olives,  which  contain  1.8  per  cent.  Further- 
more, ripe  olives  are  more  easily  digested.     Five  ripe  or 


THE  CARBOHYDRATE  IN  VARIOUS  FOODS         67 

10  green  olives  contain  1  gram  carbohydrate  and  5  grams  of 
fat.    The  quantity  of  protein  in  ten  oHves  is  about  1  gram. 

7.  Milk. — The  carbohydrate  in  milk  is  in  the  form  of 
lactose  and  can  be  reckoned  at  5  per  cent.,  or  1.5  grams 
per  30  c.c,  or  1  ounce.  It  is  the  same  in  skimmed  milk, 
buttermilk  and  whey;  but  cream  and  koumiss  contain  about 
3  per  cent.,  or  1  gram  carbohydrate  to  the  ounce.  Butter- 
milk contains  essentially  the  same  quantity  of  carbohydrate 
and  protein  as  milk,  but  only  a  trifling  amount  of  fat. 

8.  Oatmeal. — Oatmeal  is  two-thirds  carbohydrate.  In  cal- 
culations one  should  always  be  guided  by  the  dry  weight, 
because  the  different  preparations  vary  greatly  in  bulk  and 
weight  when  cooked.  It  is  a  simple  matter  for  a  few  days  to 
weigh  out  30  grams  (1  ounce)  of  dry  oatmeal  containing 
20  grams  carbohydrate,  have  it  cooked  and  note  the  bulk. 
By  dividing  the  oatmeal  thus  cooked  into  four  portions 
each  would  contain  5  grams  carbohydrate. 

In  weighing  foods  with  the  usual  variety  of  scales  one 
should  never  attempt  to  weigh  out  quantities  as  small  as  5 
grams.  A  more  reliable  result  is  obtained  by  weighing  out 
multiples  of  5  grams  and  then  dividing  into  enough  portions 
to  make  each  portion  5  grams. 

A  Shredded  Wheat  Biscuit,  weight  30  grams,  can  be  used 
interchangeably  with  30  grams  of  oatmeal.  Its  uniform 
size  and  its  availability  at  all  times  make  it  an  extremely 
convenient  article  of  food  for  a  diabetic  patient. 

Carbohydrate.  Protein  Fat. 

Oatmeal,  30  grams  (dry) 20                  5  2 

Shredded  Wheat  Biscuit     .....      23                 3  0 

Uneeda  Biscuits  (4) 20                 3  2 

9.  Bread. — It  is  undesirable  to  give  bread  to  diabetic 
patients  unless  their  tolerance  is  very  high,  because  they 
can  take  so  little  without  causing  glycosuria  that  the  bread 
is  simply  an  aggravation.  An  error  in  the  weight  of  1  ounce 
of  a  5  per  cent,  vegetable  amounts  to  1  gram  carbohydrate, 
of  potato  to  6  grams,  but  of  bread  to  18  grams.  The  car- 
bohydrate in  white  wheat  bread  amounts  to  about  53  per 
cent.    If  the  bread  is  toasted,  enough  water  is  lost  to  raise 


68  DIET  OF  DIABETIC  INDIVIDUALS 

the  percentage  of  carbohydrate  in'  the  toast  to  about  60  per 
cent.  If  tlie  bread  is  made  -with  water  instead  of  milk,  but 
without  sugar,  the  carbohy(h-ate  content  is  lowered  and  may 
amount  to  only  45  per  cent.  Coarse  breads  if  made  without 
sweetening  or  milk  would  contain  slightly  less  carbohydrate. 
If  the  tolerance  for  carbohydrate  is  less  than  50  grams,  breads 
are  best  aNoided. 

Crackers  and  zwieback  conttiin  still  less  water  than  toast, 
and  in  consequence  the  percentage  of  carbohydrate  is 
raised  to  the  neighborhood  of  70  per  cent.  Many  gluten 
breads  upon  the  market  contain  as  much  as  .SO  per  cent, 
carbohydrate. 

Protein  in  the  Diabetic  Diet. — The  quantity  of  protein 
required  by  diabetic  patients  varies  with  the  age,  weight 
and  acti\ity  of  the  case  as  well  as  with  the  condition  of 
the  kidneys.  It  is  a  safe  rule  at  the  beginning  of  treatment 
to  attempt  to  increase  the  protein  gradually  up  to  the  same 
quantity  as  that  required  by  a  normal  indi^•idual.  This  is 
approximately  1.5  grams  per  kilogram  body  weight. 

Chittenden  points  out  that  GO  grams  (one-half  the  old 
standard  protein)  are  quite  sufficient  to  meet  all  the  real 
physiological  needs  of  the  body  under  ordinary  conditions 
of  life,  and  that  with  most  individuals  not  leading  an  acti^'e 
out-of-door  life  even  smaller  amounts  will  suffice.  Chitten- 
den, weighing  57  kilograms,  and  Mendel  weighing  70  kilo- 
grams, li^•ed  respectively  on  34  and  41  grams  protein  daily, 
the  former  for  nine  and  the  latter  for  seven  months.  Until 
the  Chittenden  low  protein  diet  is  proved  to  be  entirely 
satisfactory  as  a  permanent  diet  for  healthy  individuals  it  is 
best  not  to  have  recourse  to  it  for  long  i)eriods  in  the 
treatment  of  diabetes.  Temporarily  small  quantities  may 
be  given,  but  safety  lies  not  far  from  1  gram  protein  to  each 
kilogram  body  weight. 

It  has  been  claimed  that  ^'egetable  proteins  gi^•e  rise  to 
less  carbohydrate  than  do  animal  proteins.  As  a  matter  of 
fact,  carbohydrate  may  be  formed  out  of  any  protein. 

Meat  and  Fish. — These  two  articles  constitute  the  chief 
sources  of  protein  in  the  diabetic  diet.  The  study  of  the 
chemical  composition  of  these  foods  is  simplified  for  the 


PROTEIN  IN  THE  DIABETIC  DIET  69 

diabetic  patient  by  the  fact  that  except  in  liver  and  shell-fish, 
carbohydrate  is  absent.  Even  in  liver  the  quantity  of  car- 
bohydrate is  almost  negligible  when  we  consider  the  amount 
and  frequency  with  which  this  article  of  food  is  eaten.  The 
analyses  of  liver  and  shell-fish  will  be  found  in  the  tables  on 
pages  157,  158. 

The  chief  difficulty  in  computations  of  the  nutritive  value 
of  meat  and  fish  is  due  to  the  varying  content  of  fat.  Thus, 
the  edible  portion  of  chicken  may  contain  on  the  average 
only  2.5  per  cent,  of  fat,  whereas  lean  ham  may  contain  14 
per  cent,  of  fat,  fat  ham  as  much  as  50  per  cent,  and  smoked 
bacon  65  per  cent.,  though  lean  smoked  bacon  42  per  cent. 
In  general  a  mixtiu-e  of  cooked  lean  meats  probably  contains 
not  far  from  10  to  15  per  cent,  of  fat. 

Fish  differs  from  meat  chiefly  in  the  small  quantity  of  fat. 
Even  salmon,  which  contains  more  fat  than  most  other  fish, 
showed  in  its  analysis  only  12.8  per  cent,  fat,  shad  9.5  per 
cent,  and  herring  and  mackerel  7.1  per  cent.  In  general 
other  kinds  of  fish  show  6  per  cent,  or  less  of  fat.  Halibut 
steak,  for  example,  contains  5.2  per  cent,  and  cod  0.4  per 
cent.  Preserved  fish,  however,  is  quite  rich  in  fat;  thus 
sardines  contain  19.7  per  cent.  In  substituting  fish  for  meat, 
my  patients  are  taught  to  add  from  ^  to  1  teaspoonful  of 
olive  oil  to  the  diet  for  each  30  grams  of  fish. 

The  quantity  of  protein  in  meat  also  varies  considerably 
and  usually  falls  as  the  percentage  of  fat  rises.  A  value  of 
20  per  cent,  for  protein  in  uncooked  lean  meat  represents 
about  the  average,  and  this  is  increased  to  25  per  cent,  or 
more  when  the  meat  is  cooked.  The  quantity  of  protein  in 
fish  is  very  slightly  less  than  that  in  meat.  Fish  is  especially 
desirable  in  the  early  days  of  protein  feeding  following  the 
preliminary  carbohydrate-feeding  days,  because  in  fish  the 
quantity  of  fat  is  so  low.  Shell-fish  make  agreeable  additions 
to  the  diet:  (1)  they  are  desirable  because  they  are  pala- 
table; (2)  they  are  bulky  foods  and  so  are  satisf^dng;  (3) 
they  furnish  a  separate  coiu"se  at  a  meal.  Half  a  dozen 
oysters  or  clams  are  quite  sufficient.  The  edible  portion 
of  a  medium-sized  oyster  on  the  shell  weighs  on  the  average 
half  an  ounce,  and  half  a  dozen  oysters  would  amount  to 


70  DIET  OF  DIABETIC  INDIVIDUALS 

90  to  100  grams.  The  six  would  contain  about  4  grams 
carbohydrate,  G  grams  protein  and  1  gram  fat,  the  equivalent 
of  50  calories.  Half  a  dozen  clams  on  the  shell  (edible  por- 
tion) weigh  35  grams  and  contain  0.7  gram  carbohydrate, 
3  grams  protein  and  a  negligible  quantity  of  fat. 

Eggs. — Next  to  meat  and  fish,  eggs  are  the  most  frequent 
source  of  protein  for  the  diabetic.  (These  have  already  been 
discussed  on  page  56.) 

Cheese. — Cheese  is  a  prolific  source  of  protein  and  is  to  be 
recommended  because  of  its  lesser  cost.  A  gram  of  protein 
in  cheese  is  considerably  less  expensive  than  a  gram  of  protein 
in  the  form  of  meat,  fish  or  eggs.  Unfortunately,  most 
varieties  of  cheese  upon  the  market  contain  large  percentages 
of  fat.  Even  skimmed-milk  cheese  may  contain  as  much  as 
15  per  cent. 

Broths. — Broths  are  so  extensively  used  on  fasting  days 
and  as  lunches  for  diabetic  patients  that  their  composition 
deserves  notice.  Jelly-like  broth  contains  a  large  quantity 
of  protein  in  the  form  of  gelatin,  and  such  broths  may  prevent 
diabetic  patients  from  rapidly  becoming  sugar-free  when 
they  are  consumed  freely  on  otherwise  fasting  days.  As  a 
rule,  the  nutritive  value  of  a  broth  made  for  diabetic  patients 
should  be  negligible.  That  this  may  be  the  case,  the  broth 
should  be  skimmed  free  of  fat,  and  obviously  should  be  clear 
so  as  to  be  free  from  particles  of  meat  fiber.  Various  canned 
bouillons  and  bouillon  cubes  contain  very  little  nourishment. 
(See  page  159.)  The  danger  in  broths  lies  in  the  amount  of 
salt  which  they  contain.  Frequently  this  is  very  great, 
whereas  the  amount  of  salt  should  be  moderate.  Patients 
often  desire  to  drink  several  cups  of  broth  a  day,  and  if  the 
broth  is  heavily  salted  a  portion  of  the  salt  may  not  be 
excreted.  Each  teaspoonful  of  salt  that  remains  in  the  body 
holds  back  with  it  approximately  one  pint  of  water.  This 
frequently  causes  temporary  swelling  of  the  lower  extremities 
and  face,  a  condition  which  is  more  annoying  than  dangerous. 

Considerable  variety  can  be  obtained  in  the  broths  suit- 
able for  patients.    These  are  described  on  page  146. 

Fat  in  the  Diabetic  Diet. — Fat  forms  the  bulk  of  the 
diabetic  patients'  diet.    Even  with  the  most  modern  ideas 


FAT  IN  DIABETIC  DIET  71 

upon  treatment  this  statement  holds.  Fig.  11,  and 
also  Fig.  12,  give  the  proportions  which  the  different 
foodstuffs  take  in  the  diet  and  show  the  extent  to  which 
diabetic  patients  must  depend  upon  fat  to  offset  the  loss 
of  carbohydrate.  Remember  that  the  diet  of  a  healthy 
individual  of  70  kgs.  at  office  work  contains  approxi- 
mately 300  grams  carbohydrate,  yielding  (300  x  4)  "1200 
calories.  A  diabetic  patient  of  analogous  size  who  failed  to 
utilize  more  than  300  of  these  1200  calories  must  replace  the 
remaining  900  calories  with  100  grams  of  fat.  Theoretically 
this  should  be  taken  in  addition  to  the  usual  100  grams  of 
fat  in  the  normal  ration;  but  practically  this  is  seldom  neces- 
sary, because  the  diabetic  patient  is  usually  less  active  than 
the  ordinary  individual.  These  calculations  are  made  for  a 
patient  weighing  70  kilograms.  In  reality  most  diabetic 
patients  weigh  far  less  and  therefore  require  less  food. 

The  Eskimos  live  largely  upon  fat.  Diabetic  patients 
should  be  very  thankful  that  there  is  a  race  of  Eskimos 
through  which  proof  is  afforded  that  it  is  perfectly  possible 
to  maintain  life  on  a  diet  in  which  carbohydrate  is  largely 
replaced  by  fat. 

How  much  fat  should  a  diabetic  patient  eat?  This  does 
not  depend  upon  the  capacity  of  the  digestion.  The  safest 
answer  would  be :  as  little  as  possible  in  order  to  maintain 
body  weight.  Unquestionably  the  quantity  will  vary  from 
time  to  time,  and  it  may  increase  with  years  without  detri- 
ment to  the  patient.  Nevertheless,  it  is  reassuring  to  see  a 
diet  which  contains  more  carbohydrate  than  fat.  In  other 
words,  a  carbohydrate-fat  ratio  of  2  to  1  or  1  to  1,  respectively, 
begets  confidence  and  a  carbohydrate-fat  ratio  of  1  to  5 
or  above  causes  apprehension.  Yet  case  No.  664,  with  dia- 
betes of  fifteen  years'  duration,  lives  upon  a  diet  which  con- 
tains twice  as  much  fat  as  carbohydrate,  and  for  years  the 
ratio  was  nearer  1  to  4  or  even  1  to  5. 

Fat  is  most  agreeably  taken  as  cream,  and  cream  which 
contains  20  per  cent,  butter  fat  is  usually  easier  to  bear 
than  a  richer  cream.  The  upper  120  c.c.  (4  oz.)  of  a  quart 
bottle  of  milk  w^hich  has  stood  for  twenty-four  hours  is  20 
per  cent,  cream.    It  is  seldom  advisable  to  allow  more  than 


72  DIET  OF  DIABETIC   INDIVIDUALS 

half  a  pint  (240  c.c.)  of  ciram,  althougli  patients  prefer  to 
increase  the  quantity  of  cream  at  the  expense  of  other  forms 
of  fat  in  the  diet.  Half  a  pint  of  20  per  cent,  cream  contains 
4S  grams  of  fat,  and  yet  the  quantity  of  carbohydrate  or  of 
protein  in  cream  of  this  richness  is  but  little  over  S  grams, 
and  may  be  estimated  in  clinical  work  as  S  grams,  or  1  gram  to 
the  ounce.  Occasionally  patients  tolerate  butter  better  than 
cream,  and,  as  a  rule,  fresh,  unsalted  butter  is  preferred. 
Obviously,  when  cream  is  increased  in  the  diet  the  l)utter 
must  be  decreased,  and  rice  rcr.va.  Thirty  grams  of  butter 
contain  25  grams  of  fat,  and  this  is  a  welcome  addition  to  the 
diet.  Oleo,  butterine  and  nut  margarine  contain  no  sugar 
and  haA-e  about  the  same  percentage  of  fat  as  butter,  and  the 
cost  is  very  much  less.  Lard  being  nearly  100  per  cent,  fat 
can  be  used  to  advantage  more  than  it  is  now  in  the  diabetic's 
diet.  Crisco,  also  nearly  100  per  cent,  fat,  is  often  more 
welcome  than  lard,  because  of  the  lack  of  flavor.  Oil  is  100 
per  cent.  fat. 

Oil  is  so  desirable  for  a  diabetic  that  it  is  inachisable  for  a 
patient  to  take  more  than  15  grams  (1  tablespoonful),  lest 
he  weary  of  the  same.  If  oil  is  disliked  upon  vegetables  it 
can  be  taken  in  small  quantities  as  medicine  after  meals. 
Italian  patients  naturally  bear  olive  oil  unusually  well. 
Olive  oil  forms  an  excellent  lunch  for  diabetic  patients.  It 
may  be  used  upon  retiring.  It  is  the  diabetic  patients'  cough 
medicine  and  relieves  the  symptoms  of  his  hyperacid  stomach. 
Peanut,  corn  or  cotton-seed  oil  may  be  substituted  if  expense 
is  a  factor.     Mineral  oil  is  without  nutriti\e  value. 

Danger  of  Fat  to  the  Diabetic. — Fat  is  the  chief  source  of 
the  dreaded  acidosis,  though  to  this  in  some  degree  protein 
contributes  as  well.  Fat,  therefore,  at  one  time  may  pre- 
serve the  life  of  the  dial)etic,  because  of  its  high  nutritive 
value,  but  at  another  period  may  destroy  it  by  causing  acid 
poisoning.  The  close  dependence  of  acidosis  u])on  a  fat 
diet  is  beautifully  shown  in  Table  15,  page  73. 

There  is  no  more  potent  agency  in  the  prevention  of  acidosis 
than  the  withdrawal  of  fat  from  the  diet.  Allen  has  made 
us  all  his  debtors  by  a  series  of  exi)eriments  upon  diabetic 
dogs  which  show  the  insidious  way  in  which  fat  is  harmful 


ALCOHOL 


73 


in  the  manner  in  which  it  has  been  customarily  employed 
in  the  treatment  of  diabetes.  "  Fat  unbalanced  by  adequate 
quantities  of  other  foods  is  a  poison." 

Table  15. — The  Dependence  of  Acidosis  upon  the  Fat  ix  the 
Diet  (Williams  and  Dresbach). 


Urine. 

Diet. 

Date. 

Diacetic 

Total 
NH3 

Total 
sugar 

Carbo- 
hydrate, 
grams. 

Protein,  i 

Fat, 

acid. 

(Folin), 
grams. 

(polar) , 
grams. 

grams. 

grams. 

1912 

i 

July     5 

+  + 

1.9 

48 

20 

100 

200 

6 

+  + 

2.1 

27 

65 

100 

200 

27 

+ 

0.6 

30 

90 

33  : 

74 

Aug.     8 

+  + 

2-.  7 

86 

190 

75 

200 

Oct.   20 

+ 

0.6 

45 

64 

75     j 

30 

31 

0 

0.3 

38 

45 

75 

30 

Nov.  12 

0 

0.5 

56 

56 

75 

30 

1913 

_ 

Jan.   28 

+  +  + 

2.6 

122 

35 

100 

200 

Feb.     2 

+  +  + 

3.0 

152 

66 

90 

200 

June  12 

+  +  +  + 

4.1 

108 

90 

100 

200 

July  27 

+  +  +  + 

4.4 

123 

200 

150 

180  + 

31 

++  +  + 

3.3 

172 

200 

150 

180  + 

Today  an  endeavor  is  already  made  to  protect  the  patient 
from  acid  poisonmg  by  Hmiting  the  quantity  of  fat  to  the 
amount  that  he  can  bear.  In  a  routine  way  this  is  accom- 
plished by  decreasing  the  fat  when  there  is  any  sign  of  acid 
poisoning,  but  eventually  this  will  probably  be  more  accu- 
rately accomplished  by  tests  of  the  quantity  of  fat  in  the 
blood. 

Alcohol. — The  use  of  alcohol  in  diabetes  would  seem  to  be 
indicated,  but,  as  a  matter  of  fact,  there  is  but  a  small  per- 
centage of  my  patients  who  employ  it  at  all.  1  c.c.  of  pure 
alcohol  yields  7  calories  in  its  combustion.  Thus,  15  c.c. 
(1  tablespoonful)  of  alcohol  or  its  equivalent — 30  c.c.  (2 
tablespoonfuls)  of  whisky,  brandy,  rum  or  gin — would  yield 
105  calories  to  the  body.  Seldom,  however,  do  I  prescribe 
it  for  patients,  and  this  rule  holds  even  for  patients  durmg 
days  of  fasting. 


74  DIET  OF  DIABETIC  INDIVIDUALS 

Most  of  the  physicians  of  my  acquaintance  treat  the  vast 
majority  of  their  patients  without  alcohol  in  any  form. 

Liquids. — It  is  rarely  necessary  to  restrict  the  liquids  in 
(liahetcs.  The  diminution  of  the  carbohydrate  in  the  diet 
with  the  resulting-  fall  in  the  quantity  of  the  sugar  to  be 
excreted  usually  leads  to  a  corresponding  diminution  in  the 
thirst  and  volum^  of  urine.  A  doctor  hesitates  to  restrict  a 
patient  with  severe  diabetes  in  the  use  of  liquids  for  fear  too 
little  fluid  will  be  available  for  the  body  with  which  to 
eliminate  the  acids  which  may  have  been  formed.  On  the 
other  hand,  patients  often  upset  the  digestion  by  drinking 
large  quantities  of  liquids  rapidly.  This  is  avoided  by  allow- 
ing only  half  a  glass  of  water  at  a  time,  though  the  patient  is 
instructed  to  take  that  as  frequently  as  desired. 

Case  No.  1196  continually  voided  large  quantities  of  urine, 
but  investigation  usually  revealed  a  cause,  such  as  the  inges- 
tion of  20  or  more  grams  of  salt,  bouillon  cubes  in  variable 
number  or  21  half-grain  saccharin  tablets  a  day.  Ice  water 
should  be  discouraged;  it  may  not  alwaj^s  upset  the  diges- 
tion, but  it  does  invariably  call  for  the  expenditure  of  calories 
to  warm  it  to  blood  heat,  and  calories  for  such  a  purpose  a 
diabetic  cannot  well  spare. 

Sodium  Chloride. — Salt  is  of  great  service  to  the  diabetic 
patient.  If  it  is  withdrawn  from  the  diet  the  weight  falls, 
due  to  the  simultaneous  excretion  of  water,  and  the  skin  and 
tissues  of  the  patient  are  obviously  dry. 

In  the  early  days  of  fasting  treatment,  patients  often  lost 
much  weight  because  water  alone  was  allowed.  For  example, 
one  case  lost  thirteen  pounds  in  four  days  in  this  manner. 
When  broths  are  freely  given  during  fasting  it  is  not  uncom- 
mon, particularly  in  the  presence  of  acidosis,  to  see  a  patient 
gain  weight,  and  invariably  such  patients  feel  better  than 
those  who  lose. 

This  gain  in  weight  is  to  be  explained  by  the  large  quantity 
of  salt  in  the  broths.  Salt  is  very  freely  used  by  diabetic 
patients.  I  do  not  remember  to  have  ever  seen  a  diabetic 
patient  who  took  too  little  salt,  though  such  a  case  has  been 
called  to  my  attention  at  another  clinic.  One  of  my  fasting 
cases  was  accustomed  to  shake  salt  into  his  hand  to  eat. 


SODIUM  CHLORIDE  75 

Patients   will   often   salt   their  broths,    although  these  fre- 
quently already  contain  too  much. 

The  fact  that  it  is  harmful  for  a  diabetic  patient  to  take 
large  quantities  of  salt  is  occasionally  shown  by  the  excessive 
quantities  of  urine  which  they  are  obliged  to  void,  though 
sugar-free,  and  by  the  swelling  in  legs  and  ankles  which 
may  appear.  However,  it  should  be  stated  that  it  is  most 
exceptional  for  a  patient  with  dropsy  to  develop  diabetic 
coma,  and  I  recall  but  one  instance  of  a  patient  in  diabetic 
coma  in  whom  dropsy  appeared.  The  withdrawal  of  salt 
from  the  diet  of  Case  No.  1378  wrought  surprising  changes 
in  her  weight  and  her  dropsy  entirely  disappeared.  From  98 
pounds  it  fell  to  70  pounds  in  twenty-five  days,  and  this  was 
due  almost  exclusively  to  the  disappearance  of  the  dropsy. 
If  the  quantity  of  the  urine  in  twenty-four  hours  does  not 
exceed  1500  c.c.  (3  pints)  the  amount  of  salt  in  the  diet  is 
seldom,  if  ever,  too  great. 


CHAPTER   IX. 
THE   DH^TETIC   TliEAT.AH^NT   OF   DIABETES. 

IxTRODUCTiox. — The  purpose  of  the  dietetic  treatment  of 
diabetes  is  to  enable  the  patient  by  the  rearrangement  of 
his  diet  to  lead  a  useful  life.  He  may  be  m-ged  to  live  less 
strenuously,  but  he  can  at  least  live  in  a  manner  similar  to 
that  of  a  healthy  individual.  This  object  is  best  obtained 
by  preventing  the  loss  of  sugar  in  the  urine,  in  other  words, 
by  keeping  the  urine  sugar-free. 

It  is  explained  to  the  patient  that  whereas  the  sugar  in 
the  urine  is  chiefly  dependent  upon  the  sugai-  and  starch  in 
the  diet,  the  simple  reduction  of  the  total  quantity  of  the 
diet  may  result  in  its  elimination;  that  this  reduction  of  the 
total  caloric  value  of  the  diet  is  most  easily  effected  by 
giving  up  fats  in  all  forms;  that  in  order  to  determine  how 
much  of  the  balance  of  the  diet,  now  consisting  of  carbo- 
hydrate (sugar  and  starch)  and  protein,  is  unassimilated 
and  appears  in  the  urine,  certain  articles  of  food  should  be 
selected  whose  composition  is  simple  and  well  known;  that 
the  quantities  of  these  foods  taken  in  each  twenty-four  hours 
should  be  weighed  or  measured;  that  the  facts  so  obtained 
should  be  reported  to  the  physician,  and  finally,  in  order  to 
show,  the  result  of  the  diet,  a  specimen  of  the  urine  saved 
from  the  twenty-four  hour  amount  be  sent  for  examination. 

Until  recently  the  urine  furnished  the  best  guide  to  the 
physician  as  to  whether  the  patient  was  upon  a  proper  diet. 
Today  the  examination  of  the  blood  affords  information, 
which  is  of  additional  and,  in  some  respects,  of  superior  value. 
If  the  sugar  in  the  blood  can  be  maintained  in  the  neighbor- 
hood of  the  normal  quantity  (0.10  per  cent.),  sugar  does  not 
a])pear  in  the  urine  save  in  exceptional  cases.  Usually  sugar 
is  not  found  in  the  urine  until  the  blood  sugar  is  increased  to 
0.17  per  cent.  Therefore,  abnormalities  are  earlier  apparent 
(76) 


DIETETIC  TREATMENT  OF  DIABETES  77 

in  the  blood  than  in  the  urine,  and  consequently  if  a  patient 
has  a  normal  blood  sugar  he  knows  he  is  in  a  safer  condition 
than  when  he  simply  is  informed  that  the  urine  is  sugar-free. 
However,  the  knowledge  of  the  blood  sugar  is  recent  and  too 
categorical  statements  should  not  be  made. 

Treatment  of  mild  cases  of  diabetes,  like  the  treatment  of 
all  types  of  diabetes,  can  be  carried  out  in  various  w^ays. 
There  is  no  hard  and  fast  rule.  One  of  the  simplest  pro- 
cedures, as  suggested  above,  is  to  decrease  the  total  quantity 
of  the  diet,  irrespective  of  its  quality,  to  such  a  poin  as  will 
bring  about  a  slight  loss  of  weight.  Occasionally  this  is  all 
that  is  necessary  to  free  the  urine  from  sugar.  This  is  the 
explanation  of  the  "milk  cure"  and  "potato  cure"  of  former 
times.  Those  exclusive  diets  were  undernutrition  diets. 
]\Iore  commonly,  however,  impatience  on  the  part  of  the 
doctor  and  patient  defeats  such  a  plan  and  the  urine  is  first 
rendered  sugar-free  by  the  omission  of  such  carbohydrate 
foods  from  the  diet  as  sugar,  sweetened  desserts,  bread  or 
potato.  While  this  treatment  may  work  w^ell  in  some  cases, 
it  leaves  too  much  to  chance  to  be  successful  in  all.  In  certain 
instances  it  may  even  be  harmful,  because  the  omission  of 
so  much  carbohydrate  from  the  diet  without  simultaneous 
omission  of  fat  may  lead  to  acid  poisoning,  and  acid  poison- 
ing is  a  serious  handicap  to  a  diabetic  patient.  The  mere 
development  of  acid  poisoning  transfers  the  individual,  at 
least  temporarily,  from  the  mild  to  one  of  the  severe  types 
of  the  disease.  It  is  for  these  reasons  that  the  following 
rather  more  laborious  plan  of  dietetic  treatment  is  recom- 
mended. No  apology  is  offered  for  the  added  work  entailed 
upon  both  doctor  and  patient,  because  diu-ing  these  first  few 
weeks  of  treatment,  foundations  are  being  laid  upon  which 
years  of  usefulness  and  comfort  can  rest. 

The  patient  is  requested,  for  the  sake  of  convenience,  to 
select  his  diet  from  the  following  list  of  foods.  He  is  cautioned 
to  be  moderate  in  all  that  he  eats,  and;  for  simplicity  in 
weighing  the  food,  to  narrow  his  choice  to  a  few  articles. 
.  Water,  clear,  thin  broths,  coffee,  tea,  cocoa  shells  or  cracked 
cocoa  (strained)  may  be  taken  as  desired,  and  it  is  unneceS' 
sary  to  report  the  amounts  of  each. 


7S  DIETETIC  TREATMENT  OF  DIABETES 


Table  16. — Articles  from   Which   the   Preliminary    Diet  of  a 
Mild  Diabetic  can  be  Selected. 

Total  quantity  to  be  filled  in  by  the 
Food.  patient  and  sent  to  the  physician. 

1.  Orange  (small)         Report  in  number. 

2.  Sliredded  Wheat "         pieces. 

3.  Milk "         cubic  centimeters  or 

ounces. 

4.  Fish "         grams  or  ounces. 

5.  Meat  (lean) "  "  " 

G.  5  per  cent,  vegetables  ....  "  «  « 

7.  Potato "  "  " 

8.  Bread " 


Physicians  and  patients  are  often  surprised  that  the  urine 
has  become  sugar-free  upon  this  diet,  not  realizing  that  it 
represents  a  great  reduction  in  nutritive  vahie,  due  to  the 
exchision  of  most  of  the  fat.  If  the  urine  does  not  promptly 
become  sugar-free  upon  it,  a  study  of  the  diet  list  submitted 
Avill  show  the  total  quantity  of  carbohydrate  and  protein 
which  it  contains,  and  this  compared  with  the  sugar  in  the 
urine  will  indicate  what  further  restriction  or  modification 
is  necessary. 

The  plan  as  above  described  is  intended  only  for  those 
diabetics,  presumably  mild,  who  are  about  to  begin  treat-, 
ment.  However,  it  may  be  used  by  other  diabetics  as  a 
test  diet  according  to  the  following  rule:  Select  from  the 
above  list  of  foods  those  which  occur  in  your  present  diet 
and  in  the  same  quantities  and  eat  nothing  else. 

Five  cases  will  now  be  described  to  illustrate  the  treatment 
of  diabetes  under  varying  conditions.  The.se  five  cases, 
A,  B,  C,  D,  E,  represent  t^-pes  of  diabetes  from  the  very 
mild  to  the  very  severe.  Instead  of  being  described  as  five 
separate  individuals  they  are  described  as  an  individual 
whose  case  has  become  steadily  more  serious  because  of 
lack  of  treatment.  The  data  for  urine  and  diet  do  not  exactly 
correspond  with  actual  cases  which  have  been  under  my  care, 
but  the  differences  are  slight.  By  choosing  foods  and  figures 
which  are  easy  for  calculation  the  methods  employed  are 
more  readily  to  be  understood. 


DIETETIC  TREATMENT  OF  DIABETES  79 

Test  Diets  with  Illustrated  Cases.  Case  A. — ^Mild 
Diabetes.  Let  us  for  illustration  assume  that  a  fat  man 
in  middle  life,  weight  90  kilograms  (90  x  2.2  =  198  pounds), 
has  just  learned  that  the  urine  which  he  sent  to  his  physician 
contained  1  per  cent,  of  sugar.  The  volume  of  the  urine 
amounts  to  2000  c.c.  (2  liters  or  2  quarts  and  2  ounces),  and 
the  total  quantity  of  sugar  (2000  x  0.01)  is  20  grams,  or  f  of 
an  ounce.  He  is  given  directions  to  live  upon  a  diet  in 
accordance  with  Table  16  and  in  two  days  again  reports  to 
his  physician.  The  urine  now  amounts  to  1500  c.c.  and 
contains  no  sugar.  The  record  of  the  diet  which  the  patient 
brings,  its  values  as  computed  in  carbohydrate,  protein  and 
fat,  is  shown  (Table  17)  as  Test  Diet  No.  1. 
Table  17. — Test  Diet  No.  1. 

Food.  Total  quantity.  Carbohydrate.  Protein.        Fat. 

Orange  (small)      .      .  3  (300  grams  pulp)      30  0               0 

Shredded  Wheat  .      .  1  23  3               0 

Milk 480  c.c.  (16  oz.)  24  16  16 

Fish 120  gm.  (4    oz.)  0  24               0 

Meat 150  gm.  (  5  oz.)  0  40  25 

5  per  cent,  vegetables^  300  gm.  (10  oz.)  10  5               0 

Potato        .      .      .      .  240  gm.  (  8  oz.)  48  8               0 

Bread 180  gm.  (  6  oz.)  108  18               0 

243  114  41 

The  summaries  show  that,  as  a  result  of  the  simple  request 
to  limit  the  diet  to  a  definite  group  of  foods,  the  carbo- 
hydrates and  fat  have  been  reduced  to  about  half  the  normal, 
whereas  the  protein  remains  the  same.  This  is  also  evident 
from  a  study  of  the  calories.  A  man  of  90  kilograms,  like 
Case  A,  requires  for  office  work  not  far  from  30  calories  per 
kilogram  or  2700  calories.  This  diet  contains  1797  calories, 
or  about  20  calories  per  kilogram  body  weight.  The  dis- 
tribution of  the  calories  among  the  various  foodstuffs  is  as 
follows : 

Carbohydrate 243  gm.    X   4    =   972  calories. 

Protein 114  gm.    X   4    =   456         " 

Fat 41  gm.    X   9    =   369 

Total  calories    =    1797 

^Consider  each  30  gm.  (1  oz.)  of  a  mixture  of  5  per  cent,  vegetables  to 
contain  1  gm.  carbohydrate. 


so  DIETETIC   THEATMEXr  OF  DIABETES 

Tppn  this  such  a  patient  would  lose  weiglit,  hut  even  if 
he  lost  37  pounds — the  average  abo\'e  normal  of  320  of  my 
cases  of  diabetes  over  thirty-nine  years  of  age — his  weight 
would  t'onform  to  that  of  a  normal  individual  o  feet  S  inches 
high.  Whether  before  this  point  was  reached  the  carbo- 
hydrate or  fat  in  the  diet  should  be  increased  would  depend  in 
part  upon  the  urine,  the  sugar  and  fat  in  the  blood  and  upon 
such  other  factors  as  the  mental  attitude,  the  en^^ironment 
and  the  demands  ui)on  the  individual  in  his  daily  work. 

Case  B. — Mild  l)ial)etes.  This  case  reseml)les  in  all 
essentials  the  individual  described  as  Case  A,  but  (1)  the 
analysis  of  the  first  specimen  of  urine  shows :  volume,  2500 
c.c;  sugar,  2  per  cent.;  total  sugar,  50  grams.  (2)  After 
living  for  two  days  upon  Diet  No.  I  the  urine  does  not 
l)ecome  sugar-free,  but  the  analysis  is  as  follows:  volume, 
2000  c.c;  sugar,  1  per  cent.;  total  sugar,  20  grams. 

What  is  to  be  done?  As  stated  above  it  is  quite  probable 
that  persistence  upon  this  diet  with  the  consequent  decrease 
in  the  weight  of  the  patient  would  eventually  result  in  the 
urine  becoming  sugar-free.  iNIore  rapid  results  being  desired, 
recourse  is  had  to  two  expedients  to  bring  this  about,  namely : 
(1)  The  further  reduction  of  the  total  diet  by  the  elimination 
of  fat  and  (2)  a  sharp  lowering  of  protein.  The  modifications 
of  the  diet  necessary  for  this  purpose  are  very  simple,  neces- 
sitating only  the  substitution  of  skimmed  milk  for  milk,  the 
replacement  of  meat  by  fish  and  the  elimination  of  bread. 
To  provide  bulk  as  an  ofi'set  to  the  bread,  5  per  cent,  vege- 
tables are  increased.    The  schedule  would  then  be  as  follows: 

Table  18.— Test  Diet  No.  2. 


Carbo- 

Food. 

Total  quantity. 

hydrate. 

Protein. 

Fat. 

Orange  (small) 

3  (300  grams  pulp) 

30 

0 

0 

Shredded  wheat    . 

1 

23 

3 

0 

Skimmed  milk 

480  c.c.  (16  o2.) 

24 

16 

0 

Fish 

300  gm.  (10  oz.) 

0 

60 

0 

.5  per  cent,  vegetables 

480  gm.  (16  oz.) 

16 

8 

0 

Potato         .... 

240  gm.  (  8  oz.) 

48 

8 

0 

141  95 


DIETETIC  TREATMENT  OF   DIABETES  81 

The  calories  in  this  diet  are  944,  or  about  10  calories  per 
kilogram  body  weight.    They  are  distributed  as  follows: 

Carbohydrate 141  gm.    X  4    =   564  calories. 

Protein 95  gm.    X   4    =   380        " 

Fat Ogm.    X   4    =       0         " 

Total  calories  944 

After  two  days  upon  this  diet  the  quantity  of  urine  falls 
to  1500  c.c.  and  the  sugar  disappears. 

The  further  course  of  Case  B  is  to  be  regulated  by  the  urine, 
the  blood  sugar  and  blood  fat  and  the  weight  as  in  Case  A. 
So  soon  as  the  blood  sugar  becomes  normal  (0.10  per  cent.) 
fat  could  be  added  to  the  diet,  very  gradually  at  first  and 
ultimately  to  such  an  extent  that  the  total  calories  will  not 
be  in  excess  of  20  calories  per  kilogram  for  the  body  weight 
at  the  given  time.  When  this  point  is  reached  the  carbo- 
hydrate could  be  tentatively  increased,  preferably  controlling 
each  addition  of  10  grams  by  a  blood  sugar  test.  Coincidently 
with  this  subsequent  increase  of  carbohydrate  the  fat  could 
be  raised  in  the  ratio  of  0.5  gram  fat  for  1  gram  carbohydrate. 
When  the  total  calories  reach  25  per  kilogram  body  weight, 
additions  to  the  diet  should  be  exclusively  as  carbohydrate. 
If  the  total  calories  are  near  the  point  where  sugar  is  to  appear 
in  the  urine  the  critical  figure  is  more  quickly  shown  by 
increasing  carbohydrate  than  the  other  foodstuffs,  and  it  is 
always  best  to  find  out  if  one  is  near  the  danger-point.  If 
sugar  does  appear  in  the  urine,  it  is  evidence  that  the  patient 
either  needs  to  lose  more  weight  or  that  his  case  must  be 
carried  along  upon  a  lower  margin  of  carbohydrate. 

■  Fat  can  be  gradually  increased  in  the  diet  in  a  very  simple 
manner.  Thus  the  substitution  of  1  egg  for  30  grams  (1 
ounce)  of  fish  adds  6  grams  of  fat  and  leaves  die  protein 
unchanged ;  the  substitution  of  30  grams  of  meat  for  the  same 
weight  of  fish  adds  5  grams  of  fat  and  2  grams  of  protein;  the 
substitution  of  milk  for  skimmed  milk  adds  1  gram  of  fat  for 
each  30  c.c.  and  the  substitution  of  cream  adds  6  grams  fat 
for  each  30  c.c.  Bacon  and  butter  will  quickly  raise  the  diet 
to  the  required  figure,  as  is  shown  in  Table  19,  page  82. 
6 


82  DIETETIC  TREATMENT  OF  DIABETES 

Table  19. — Test  Diet  No.  2,  Modification  A. 

Carbo- 
Food.  Total  quantity.  hydrate.    Protein.        Fat. 

Oranges  (small)     .      .  3  (300  grams  pulp)       30  0  0 

Shredded  Wheat  .      .  1  23  3  0 

Milk 360  c.c.  (12  oz.)  18  12  12 

20  per  cent,  cream     .  120  c.c.  (  4  oz.)  4  4  24 

Eggs 2  0  12  12 

Fish 90  gm.  (  3  or.)  0  18  0 

Meat 120  gm.  (  4  oz.)  0  32  20 

Bacon 30  gm.  (  1  oz.)  0  5  15 

5  per  cent,  vegetables  480  gm.  (16  oz.)  16  8  0 

Potato        .      .      .      .  240  gm.  (  8  oz.)  48  8  0 

Butter 30  gm.  (  1  oz.)  "0  0  25 

139  102  108 

The  calories  in  this  diet  are  1936.  If  the  weight  of  the 
patient  has  fallen  to  80  kilograms  (176  pounds)  this  would 
amount  to  about  25  calories  per  kilogram  body  weight — a 
sufficient  quantity  for  a  man  still  fifteen  pounds  above  the 
normal  average  for  his  age  and  height. 

It  is  illustrative  of  the  improvement  in  treatment  that 
five  years  ago  Case  B  would  undoubtedly  have  fallen  into  the 
class  of  moderately  severe  diabetics.  The  next  two  cases 
about  to  be  described,  Cases  C  and  D,  unquestionably  belong 
among  the  group  of  moderately  severe  diabetics.  It  is  true 
that  the  tolerance  of  Case  C  for  100  grams  carbohydrate 
would  lead  one  to  class  him  as  mild  if  carbohydrate  tolerance 
alone  was  the  deciding  factor.  He  is  perhaps  best  described 
as  mild  because  of  modern  treatment.  Case  D  conforms 
to  the  type  of  a  moderately  severe  diabetic  rated  by  the 
standards  of  both  yesterday  and  today.  For  the  sake  of  uni- 
formity and  simplicity  the  originals  of  these  Cases  C  and  D, 
Cases  Nos.  1563  and  1540  respectively,  are  described  as  the 
type  Case  A,  but  under  different  conditions,  the  features  of 
the  original  cases  being  incorporated  into  the  new  histories. 

Case  C. — Moderately  Severe  Diabetes.  Let  us  suppose 
that  our  patient  resembles  in  physical  characteristics  Case  A. 
He  has  weighed  90  kilograms  (198  pounds),  and  for  his 
height  was  16  kilograms  (37  pounds)  overweight.  In 
February,  1917,  he  passed  an  examination  for  life  insurance, 
but  during  the  following  June,  0.2  per  cent,  of  sugar  was 


DIETETIC  TREATMENT  OF  DIABETES  83 

found  in  the  urine  upon  one  occasion  and  0.4  per  cent,  upon 
another.  This  he  neglected  until  one  morning,  two  years 
later,  he  observes  his  collar  is  too  large,  thirst  is  present, 
the  urine  is  increased  and  he  remembers  he  was  once  told  he 
had  diabetes. 

The  twenty-four  hour  quantity  of  urine  which  he  takes 
to  his  physician  amounts  to  3000  c.c.  It  contains  8  per 
cent,  of  sugar,  making  a  total  of  240  grams  (one-half  a 
pound).  He  is  to  some  extent  relieved  when  he  hears  there 
is  no  evidence  of  acid  poisoning,  and  fortunately  this  does 
not  make  its  appearance  throughout  the  time  he  is  under 
observation. 

The  blood  fat  is  about  1.5  per  cent,  and  the  blood  sugar 
0.23  per  cent.  His  body  weight  is  now  80  kilograms,  a  loss 
from  his  former  weight  of  22  pounds.  He  is  told  to  select 
his  diet  from  the  articles  mentioned  in  Table  16.  For  con- 
venience assume  his  selection  was  the  same  in  quantity  and 
quality  as  Case  A,  and  is  represented  by  Test  Diet  No.  1. 
But  note  the  difference  in  the  effect  of  this  diet  as  shown 
by  the  examination  of  the  urine  at  the  end  of  two  days! 
Whereas  under  the  same  conditions  the  urine  of  Case  A  was 
sugar-free,  the  urine  of  Case  C  amounts  to  2500  c.c,  con- 
tains 6  per  cent,  sugar,  a  total  of  150  grams.  Case  C  is 
at  once  placed  upon  Test  Diet  No.  2  for  two  days.  The 
change  of  diet  is  immediately  manifested  in  the  urine. 
The  analysis  shows  a  volume  of  2000  c.c.  This  contains 
4  per  cent,  sugar,  a  total  quantity  in  twenty-four  hours  of 
80  grams.  The  result  is  gratifying  so  far  as  it  goes,  but 
obviously  greater  dietetic  reductions  must  be  made.  Test 
Diet  No.  3  is  therefore  prescribed  for  the  next  two-day 
period.  The  composition  of  Test  Diet  No.  3  is  summarized 
in  Table  20. 

Table  20.— Test  Diet  No.  3. 

Carbo- 

Food.                                 Total  quantity.  hydrate.  Protein.  Fat. 

Orange  (small)       .      .          3  (300  grams  pulp)  30  0  0 

Shredded  Wheat  .      .          1  23  3  0 

Skimmed  milk       .      .  120  c.c.  (  4  oz.)  6  4  0 

Fish 150  gm.  (  5  oz.)  0  30  0 

5  per  cent,  vegetables  480  gm.  (16  oz.)  16  8  0 

75  45  0 


S4  DIETETIC  TREATMENT  OF  DIABETES 

The  calories  in  this  (Hct  are  480,  or  (>  calories  per  kilogram 
body  Aveifiht  for  a  man  of  SO  kilograms.  They  are  dis- 
tributed as  follows : 

Carbohydrate 75  gm.    X   4    =   300  calories. 

Protein 45  Rrn.    X   4    =    180 

Fat 0  gm.    X   9    =       0         " 

Total  calories     480 

As  the  result  of  living  upon  this  diet  h)r  two  days  the 
urine  decreased  to  1500  c.c,  the  percentage  of  sugar  to  2 
per  cent.,  making  a  total  outj)ut  of  .30  grams  of  sugar  in 
twenty-four  hours.  The  change  in  diet  not  being  sufficiently 
effective,  resort  is  at  once  had  to  Test  Diet  No.  4,  shown  in 
Table  21. 

Table  21. — Test  Diet  No.  4. 

Carbo- 
Foocl.  Total  (luiuitity.  hydrate.     Protein.         Fat. 

Orange  (small)       .      .  2  (200  grams  pulp)  20  0  0 

Skimmed  milk       .      .  120  c.c.  (  4  oz.)  6  4  0 

Fish 120  gm.  (   4  oz.)  0  24  0 

5  per  cent,  vegetables  300  gm.  (10  oz.)  10  5  0 

36  33  0 

Carbohydrate 36  gm.    X   4    =    144  calories. 

Protein 33  gm.    X   4    =    132 

Fat 0  gm.    X   9    =        0 

Total  calories     276 

This  diet  cleared  the  urine  of  sugar.  The  blood  sugar 
fell  to  0.11  per  cent.,  an  approximately  normal  figure,  but 
the  blood  fat  remained  high  at  0.(S1  per  cent.,  which  is  twice 
the  normal*  On  this  latter  account  no  essential  change 
was  made  in  the  diet  during  the  next  five  days,  save  for 
the  addition  of  carbohydrate,  10  grams.  Thereafter  the 
carbohydrate  was  increased  about  5  grams  a  day,  the  pro- 
tein somewhat  less  rapidly  and  the  fat  the  least  of  all,  so  that 
on  the  fifteenth  day  after  becoming  sugar-free  the  diet  was 
that  represented  in  Te.st  Diet  No.  2,  Modification  B. 


DIETETIC  TREATMENT  OF  DIABETES 


85 


Table  22. — Test  Diet  No.  2,  Modification  B. 


Food. 
Oranges  (small) 
Shredded  Wheat 
Milk     .      .      . 


Meat  .  .  . 
5  per  cent,  vegetables 
10  per  cent,  vegetables 
Potato        .... 


C'arbo- 
Total  quantity.  liydratc. 

2  (200  grams  pulp)      20 


240  CO.  (  8  oz.) 

2 
150  gm.  (  5  oz.) 
300  gm.  (10  oz.) 
150  gm.  (  5  oz.) 
150  gm.  (  5  oz.) 


23 
12 
0 
0 
10 
10 
30 

105 


Protein. 
0 
3 
8 
12 
40 
5 
3 
5 

76 


Fat. 
0 
0 
8 
12 
^5 
0 
0 
0 

45 


Upon  this  diet  the  urine  continued  sugar-free,  the  blood 
sugar  dropped  to  0,09  per  cent.,  but  the  blood  fat  remained 
the  same  0.83  per  cent.  Subsequently,  step  by  step,  the 
diet  will  be  increased  but  no  attempt  will  be  made  to  exceed 
that  of  Test  Diet  No.  2,  Modification  k,  Table  19.  More 
frequent  examinations  of  the  urine  and  blood  also  will  be 
necessary  than  in  the  previous  two  cases. 

A  summary  of  the  treatment  of  Case  C  is  given  in  Table  23. 

Table  23. — Summary  of  Treatment  op  Case  C. 


Urine. 

Diet 

No. 

Diet  in  grams. 

Blood. 

Time. 

•a 
S 

"o 

> 

Sugar. 

6 

03 
u 

O 

'a 
o 

PL, 

03 

+3 

a 

c 

ft 

03 
CO 

1 

0 
o 

u 
<u 
Ph 

"3 
o 

ft 

03 

1917 

June 

0.4 

1919 

July 

3000 

8.0 

240 

Unrestricted 

2  days 

2500 

6.0 

150 

No.  1 

243 

114 

41 

0.23 

1.5=fc 

2  days 

2000 

4.0 

80 

No.  2 

141 

95 

0 

2  days 

1500 

2.0 

30 

No.  3 

75 

45 

0 

2  days 

1500 

0 

0 

No.  4 

36 

33 

0.11 

0.81 

15  days 

1500 

0 

0 

No.  2,  Mod.  B 

105 

78 

45 

0.09 

0.83 

later 

86  DIETETIC  TREATMENT  OF  DIABETES 

Case  D. — Moderately  Severe  Diabetes.  This  patient 
represents  a  sliglitly  more  severe  type  of  diabetes  than  Case 
C.  While  resembling  in  Aveight  and  age  Case  C,  the  original 
from  which  the  following  description  was  drawn  was  a 
woman,  the  mother  of  six  children.  The  youngest  was 
seven  years  old  in  1915,  when  the  patient  developed  dia- 
betes. At  the  first  visit  she  is  discouraged,  her  weight  has 
fallen  from  90  kilograms  (198  pounds)  in  1915  to  70  kilo- 
grams (15-1  pounds)  in  1919.  The  urine  is  irritating,  is 
estimated  to  be  over  0000  c.c.  and  a  single  specimen  con- 
tains 7.2  per  cent,  sugar.  Fortunately  there  is  no  acid 
poisoning.  Family  cares  seemed  so  compelling  that  she  at 
once  retiu-ned  home  and  attempted  to  carry  out  treatment. 
It  is  not  surprising  that  with  the  unavoidable  distractions 
of  her  large  household  she  did  not  become  sugar-free,  though 
under  the  care  of  a  competent  doctor  and  nurse.  Test  Diets 
Nos.  1,  2,  3,  4  were  successively  adopted  and  even  fasting 
attempted,  but  sugar  persisted  in  the  urine.  The  patient 
then  entered  the  hospital  and  was  placed  upon  Test  Diet  No. 
4:  carbohydrate,  36  grams;  protein,  33  grams.  At  the  end 
of  tv\'elve  hours  the  urine  showed  2  per  cent,  sugar.  Fasting 
was  now  begun  and  continued  for  three  days.  It  proved 
successful,  for  at  the  end  of  this  time  the  urine  was  sugar- 
free.  Thereupon  carbohydrate  and  protein  were  gradu- 
ally increased  and  later  fat  in  accordance  with  the  diet 
shown  in  Table  24.  It  will  not  be  necessary  to  describe 
the  changes  in  the  diet  from  daj^  to  day,  as  they  are  made 
plain  by  the  table  itself.  The  only  new  feature  introduced 
is  that  the  orange  is  given  by  weight.  Oranges  vary  so 
much  in  size  that  when  a  patient  has  a  low  tolerance  for 
sugar  it  is  unwise  to  prescribe  oranges  except  by  weight. 

During  the  period  represented  by  the  chart  the  urine 
remained  sugar-free  and  the  blood  sugar  dropped  from 
0.17  to  0.14  per  cent.  At  discharge  the  diet  prescribed 
contained  carbohydrate  57  grams,  protein  78  grams  and  fat 
61  grams.  The  favorable  course  of  this  case  like  all  those 
hitherto  described  is  to  be  explained  by  the  absence  of  acid 
poisoning  both  before  and  during  treatment.  How  impor- 
tant this  factor  is  the  next  case,  Case  E,  will  show. 


DIETETIC  TREATMENT  OF  DIABETES  87 

Table  24. — Case  D.    Gradual  Increase  in  Diet. 


Diet  in 

grams 

Dietary  prescriptions  in  grams. 

6 

Blood 

Date, 
1919. 

1 

d 
'3 

2 

PL, 

J 
o 

ll 
o  a) 

S  « 
a> 

lO 

1 
1 
o 

■  S 

M 

s 

4 
M 

ci 
M 

a 
O 

sugar, 
per 
cent. 

July 
6,  7,  8 

0 

0 

0 

0 

0.17 

9 

5 

3 

0 

32 

iVo 

10 

10 

5 

0 

60 

300 

11 

15 

8 

0 

92 

450 

12 

20 

10 

0 

120 

600 

13 

20 

18 

3 

179 

600 

30 

14 

20 

30 

3 

227 

600 

30 

60 

15 

20 

46 

9 

345 

600 

90 

60 

0.14 

16 

25 

49 

9 

377 

750 

90 

60 

17 

30 

58 

15 

487 

750 

90 

60 

90 

1 

18 

33 

66 

26 

630 

750 

90 

60 

150 

2 

19 

36 

68 

28 

668 

750 

90 

60 

210 

2 

20 

39 

69 

29 

693 

750 

90 

60 

240 

2 

20 

Case  E. — Severe  Diabetes.  The  prototype  of  this  case 
resembles  Case  A  in  all  essential  particulars  save  one,  that 
the  duration  of  the  diabetes  has  been  six  years.  He  was 
sent  to  the  New  England  Deaconess  Hospital  by  his  physi- 
cian as  a  case  of  diabetic  coma.  Special  interest  attaches 
to  this  patient  because  upon  examination  at  entrance  the 
degree  of  acidosis  (CO-  in  the  alveolar  air  by  the  Fridericia 
method  was  12  mm.  of  mercury  and  the  CO2  in  the  blood  by 
the  Van  Slyke  test  reckoned  in  the  same  terms  was  12.8) 
proved  to  be  more  severe  than  that  of  any  other  patient 
hitherto  treated  in  this  institution  who  has  recovered  and 
left  the  hospital  alive.  The  weight  had  fallen  to  60  kilo- 
grams (132  pounds). 

He  was  at  once  placed  upon  a  diet  resembling  Test  Diet 
No.  3  and  kept  upon  this  for  three  days,  and  then  upon  a 
diet  resembling  Test  Diet  No.  4,  upon  which  he  remained 
two  days.  This  was  followed  by  a  fast  of  four  days.  There- 
upon he  was  fed  for  six  days  with  Test  Diet  No.  5,  which  was 
essentially  as  shown  in  Table  25. 


ss 


DIETETIC   TREATMENT  OF  DIABETES 


T.VBLK  25. — TiOijT  1)ii:t  No.  5. 


Koocl. 

Total  quantity. 

{ "arbo- 
liydrato 

Protein. 

I'^it 

Grape  friiit 
Skimmed  milk 
Fish      .      .      . 
5  per  eeiit.  vege 

tables 

100  gm.  (3  J  oz.) 
90  c.c.  (  3  oz.) 
60  gm.  (   2  oz.) 

300  gm.  (10  o7.) 

5 

5 

0 

10 

0 

3 

12 

5 

0 
0 
0 
0 

20 


20 


Witli  two  (lays  more  of  fastint;'  the  urine  beeaine  sugar- 
free.  Tlie  course  of  treatment  up  to  this  point  and  the 
sub.sefjuent  increases  in  diet  are  shown  in  Table  2().  At 
the  end  of  six  days,  although  sugar  was  absent,  the  patient 
was  fasted  again.  He  was  eventually  discharged  from  the 
hospital  with  a  diet  containing  106:5  calories  in  the  form  of 
carboliydrate  2()  grams,  protein  80  grams  and  fat  71  grams. 


T.\BLE  26. — Course  of  C.\se  E. 


No.  of 
days. 


Average 
daily  excre- 
tion of 
sugar,  gms. 


Diet. 


Diet  in  grams. 


Carbo- 
hydrate. 


Protein. 


Fat. 


Carb. 
balance, 
grams. 


3 

115 

No.  3 

75 

45 

0 

-40 

2 

80 

No.  4 

36 

33 

0 

-45 

20 

Fast 

0 

0 

0 

-20 

30 

No.  5 

20 

20 

0 

-10 

2 

Fast 

0 

0 

0 

_    2 

0 

— 

2 

15 

9 

+   2 

0 

— 

4 

22 

14 

+   4 

0 

— 

6 

31 

18 

+   6 

0 

— 

8 

48 

24 

+  8 

0 

— 

9 

Gl 

24 

+  9 

0 

- 

11 

74 

24       ' 

+  11 

The  subsequent  course  of  this  case  would  be  carried  out 
in  a  manner  similar  to  that  described  for  Case  D.  Obviously 
the  increase  of  the  diet  would  ])rocee(l  far  more  gradually. 

For  convenience  Test  Diets  Nos.  1  to  5  are  summarized 
in  Table  27: 


DIETETIC   TREATMENT  OF  DIABETES 


SO 


Table  27.— Test  Diets,  Series  A,  in  Grams  or  Cuhic  Ciontimkters- 

Food.  I     T.  D.  1     I     T.  D.  2     I     T.  D.  3     i     T.  D.  4     1   T.  D.  5 


Orange,  very  small,  3  . 

300 

300 

300 

200 

Grape  fruit 

100 

Shredded  Wheat,  one 

30 

3(J 

30 

MUk 

480 

480 

Skimmed  milk 

120 

120 

120 

Fish 

120 

300 

150 

120 

00 

Meat 

150 

5  per  cent,  vegetables 

300 

480 

480 

300 

300 

Potato         .... 

240 

240 

Bread    

180 

Carbohydrate 

243 

141 

75 

36 

20 

Protein        .... 

114 

95 

45 

33 

20 

Fat 

41 

0 

0 

0 

0 

The  test,  diets  shown  as  Test  Diets,  Series  B,  begin  with  a 
lower  quantity  of  carbohydrate.  It  is  possible  to  employ 
this  set  of  diets  without  the  use  of  scales. 


Test  Diets,  Series  B,  in  Grams  or  Cubic  Centimeters. 


Food. 

T.  D.  1 

T.  D.  2 

T.  D.  3 

T.  D.4 

T.  D.  5 

Orange  

300 

300 

300 

200 

50 

5  per  cent,  vegetables 

300 

300 

300 

300 

300 

Skimmed  milk  . 

480 

300 

240 

120 

Fish 

120 

180 

90 

90 

Potato    

240 

120 

60 

Shredded  Wheat,  one  . 

30 

30 

Meat       ..... 

90 

Bread     

90 

Carbohydrate   . 

189 

102 

64 

36 

15 

Protein 

89 

58 

33 

27 

5 

Fat 

15 

0 

0 

0 

0 

If  the  patient  is  so  unfortunate  as  not  to  have  scales,  treatment  need  not  be 
abandoned,  but  the  following  approximate  equivalents  in  place  of  weights 
may  be  employed : 

Food.  Weight  in  grams.  Approximate  equivalent. 

Orange 300   .  .   One  and  one-half  (large  size) 

5  per  cent,  vegetables    .  300   .  .    Three  moderate  portions 

Skimmed  milk     .  480    .  .    One  pint  (16  ounces) 

Fish 120    .  .    Two  small  portions 

Potato 240   .  .   Two  medium-sized  potatoes 

Meat 90    .  .   One  moderate  portion 

Bread 90   .  .    Three  small  slices                        • 


90  DIETETIC  TREATMENT  OF  DIABETES 

Description  of  Special  Cases. — Case  No.  804  assumes 
importance  because  he  died  a  year  and  a  half  after  he  left 
tlie  hospital  in  the  eighth  year  of  the  disease.  The  advance 
in  treatment  since  1917  has  been  sufficient  to  warrant  the 
belief  that  today  his  life  could  undoubtedly  have  been  pro- 
longed with  comfort  to  himself.  Evidence  of  the  truth  of 
this  statement  is  to  be  found  in  the  description  of  Case  No. 
5(34.  At  the  time  that  Case  No.  804  was  discharged  he  was 
considered  a  successful  patient. 

Case  No.  804  contracted  diabetes  at  the  age  of  forty-two 
years,  and  first  considted  me  fom-  years  later,  December  17, 
1914,  at  the  age  of  forty-six.  His  weight  at  that  time  was 
139.  The  quantity  of  sugar  amounted  to  5.6  per  cent.,  and 
acid  poisoning  was  present.  With  restriction  of  diet  and 
fasting  he  became  sugar-free  on  December  30  and  the 
acid  poisoning  disappeared  on  January  7.  He  left  the  hos- 
pital sugar-free,  having  gained  one  pound  by  January  11, 
and  a  year  later  his  weight  was  150.  Difficulty  occurred  in 
keeping  sugar-free,  and  he  returned  for  hospital  treatment 
on  April  22,  1917,  showing  in  a  twelve-hour  specimen  2.5 
per  cent.  (66  grams)  of  sugar  and  severe  acid  poisoning. 
In  Table  28  it  will  be  seen  that  even  four  days  of  fasting  did 
not  suffice  to  rid  the  m-ine  of  sugar.  This  was  followed  by 
three  days  of  restricted  diet,  when  the  institution  of  one  fast 
day  made  the  m-ine  sugar-free.  On  May  18  he  left  the  hos- 
pital free  from  acid  poisoning  and  sugar  and  weighing  134 
pounds.  His  diet  then  contained  carbohydrate  15  grams, 
protein  71  grams,  fat  122  grams  and  alcohol  12  grams, 
making  a  total  of  1526  calories.  By  August  17  he  had  been 
able  to  increase  the  diet  to  50  grams  carbohydrate,  about 
110  grams  protein  and  110  grams  fat,  making  1600  to  1800 
calories  in  a  day  and  the  weight  had  risen  to  148  pounds. 
From  the  above  it  can  be  seen  that  the  diabetes  changed 
from  the  severe  to  the  moderate  type  and  became  at  least 
temporarily  mild.  It  is  unfortunate  that  he  was  not  under 
closer  observation  after  leaving  the  hospital. 

One  of  the  most  satisfactory  cases  of  my  series  was 
Case  No.  564,  a  boy  of  sixteen  years,  who  in  November, 
1912,  came  to  my  former  assistant.   Dr.  F.  G.  Brigham. 


DIETETIC  TREATMENT  OF  DIABETES 


91 


Table  28. — Case   No.  804.     A   Severe   Case  Tueated   by   Fasting   Who 
Subsequently  Inckeased  his  Tolerance  fob  Carbohydrate 
TO  A  Remarkable  Degree. 


Urine. 

Diet  in  grams. 

Carbo- 
hydrate, 
balance 
grams. 

Sugar. 

Carbo- 
hydrate. 

Blood 
sugar 

Diacetic  acid. 

Per  cent. 

Total 

Protein. 

Fat. 

Alcohol. 

Calories. 

per  cent. 

grams. 

+  +  +  + 

2.8 

+  + 

2.5 

66 

— 

— 

— 

— 

— 

— 

+  + 

1.3 

35 

0 

0 

0 

0 

0 

-35 

+  + 

0.8 

14 

0 

0 

0 

0 

0 

-14 

0.22 

+ 

0.8 

12- 

0 

0 

0 

0 

0 

-12 

0 

0.1 

2 

0 

0 

0 

0 

0 

-   2 

0 

0.1 

3 

0 

30 

6 

9 

237 

-  3 

+ 

0.1 

3 

0 

46 

22 

12 

466 

-  3 

0 

0.2 

6 

0 

51 

37 

12 

621 

-  6 

0 

0 

0 

0 

0 

0 

30 

210 

0 

+ 

-0.1 

0 

0 

35 

33 

18 

563 

0 

0.15 

si.  + 

-0.1 

0 

0 

50 

47 

9 

886 

0 

si.  + 

0.1 

2 

0 

58 

50 

12 

766 

-  ,2 

si.  + 

0 

0 

0 

60 

59 

15 

876 

0 

si.  + 

0 

0 

1 

60 

72 

12 

976 

+   1 

0 

0 

0 

5 

63 

84 

18 

1154 

+  5 

0 

0 

0 

9 

63 

92 

9 

1179 

+  9 

0 

0.2 

4 

10 

65 

106 

9 

1317 

+  6 

0.15 

0 

0 

0 

0 

0 

0 

12 

84 

0 

0 

0 

0 

9 

63 

94 

12 

1218 

+  9 

0 

0 

0 

9 

62 

94 

9 

1193 

+  9 

0 

0 

0 

9 

62 

91 

3 

1124 

+  9 

0 

0 

0 

9 

73 

94 

6 

1216 

+  9 

0 

0 

0 

9 

68 

91 

9 

1190 

+  11 

0.10 

0 

0 

0 

11 

70 

106 

12 

1362 

+  13 

0 

0 

0 

13 

75 

118 

9 

1477 

+  15 

0 

0 

0 

15 

71 

122 

12 

1526 

+  15 

0 

0     . 

0 

15 

71 

122 

12 

1526 

+  15 

0.11 

0 

0 

0 

50 

110 

110 

1630 

+50 

Sugar  had  appeared  in  the  urine  without  previous  symp- 
toms, following  a  football  game  between  two  large  pre- 
paratory schools.  The  patient  entered  the  New  England 
Deaconess  Hospital,  where,  under  the  methods  of  treat- 
ment adopted  in  1912  and  1913,  he  remained  from  Decem- 
ber 15,  1912,  to  January  14,  1913  without  becoming  sugar- 
free,  the  quantity  of  sugar  varying  between  3.4  per  cent. 
(187  grams  in  the  twenty-four  hours)  and  0.8  per  cent.  (43 


92  DIETETIC   TREATMENT  OF  DIABETES 

grams  in  the  twenty-four  lionrs)  at  diseharge.  However, 
by  persistenee  in  tlie  crude  methods  tlien  employed,  under 
the  supervision  of  Dr.  R.  J.  Thompson,  of  Fall  River,  and 
a  nurse  thoroughly  versed  in  diabetic  treatment,  the  acid 
poisoning  which  had  been  severe  and  later  amounted  to  as 
much  as  i-;  represented  by  5.7  grams  of  annnonia  in  twenty- 
four  hours,  disappeared,  and  at  his  home  he  became  sugar- 
free  in  April,  1913.     He  is  now,  1919,  in  college. 

In  the  spring  of  1919  he  reentered  the  hospital  under  the 
care  of  Dr.  B.  H,  Ragle,  was  treated  according  to  present- 
day  principles  and  ultimately  discharged  upon  a  diet  of  car- 
bohydrate 41,  protein  92  and  fat  12")  grams;  weight  naked, 
lOS  pounds;  blood  sugar,  0.15  per  cent. 

Case  No.  632,  a  young  officer,  aged  thirty-five  years,  with 
diabetes  of  one  and  a  half  years'  duration,  came  to  me  first 
in  1913.  At  the  hospital  diacetic  acid  showed  repeatedly, 
and  the  ammonia  was  1.7  grams,  but  the  tolerance  for  carbo- 
hydrate lay  between  15  and  30  grams.  Nevertheless,  he  was 
discharged  with  0.5  per  cent,  of  sugar  in  the  urine,  and  diacetic 
acid  was  present,  with  a  diet  of  30  graius  carbohydrate  and  a 
Hmited  quantity  of  protein,  though  with  an  unlimited  amount 
of  fat.  He  returned  in  February,  191(3,  and  it  required  twelve 
days  to  free  the  urine  of  sugar  and  twenty-one  days  to  rid 
it  of  acid,  but  he  left  the  hospital  April  13,  having  been 
sugar-free  the  preceding  week,  with  a  tolerance  for  28  grams 
carbohydrate,  79  protein,  133  fat  and  9  alcohol.  The  blood 
sugar  was  0.21  per  cent.  While  at  the  hospital  exercise  was 
utilized  to  the  limit,  and,  as  to  be  expected  of  an  army  man 
with  a  Victoria  Cross,  obedience  was  implicit,  cooperation 
ever  present  and  system  exact.  Permission  has  been  obtained 
to  publish  this  letter,  received  ele\'en  months  after  leaving 

the  hospital. 

March  8,  1917. 

"I  have  reall\'  been  wonderfully  well,  feel  splendid  and 
everyone  remarks  how  well  I  am  looking.  Tests  have  shown 
a  slight  trace  of  sugar  on  tjiree  mornings  since  October  8 
last;  all  other  times  absolutely  sugar-free.  My  weight 
doesn't  change  at  all;  if  anything  I  have  gotten  very  slightly 
lighter.     I  weigh  from  124|  to  125^  pounds.     I  still  stick 


DIETETIC  TREATMENT  OF  DIABETES  93 

absolutely  rigidly  to  my  routine,  but  I  have  gotten  up  to 
30  grams  carbohydrate  per  diem — that  is,  on  the  last  five 
days  of  the  week  I  take  30 — rest  of  diet  the  same.  The  last 
three  weeks  I  have  been  taking  15  grams  oatmeal  for  break- 
fast on  Monday,  Tuesday,  Thursday,  Friday  and  Saturday 
mornings,  Wednesday  all  carbohydrate  in  5  per  cent,  vege- 
tables and  cream  and  Sunday  (fast  day)  all  carbohydrate  in 
'5  per  cent,  vegetables." 

That  this  improvement  continues  is  evident  from  another 
letter  of  October  12,  1917. 

"We  had  a  patriotic  golf  match  here  last  Saturday  and 
Monday  against  the  rival  golf  club  here.     I  was  chosen  to 

play  2d  for  the ,  and  my  opponent  and  I  came  out 

even  in  both  our  matches,  one  over  our  course  and  the  other 

over  the .    I  am  sending  you  a  new^spaper  clipping 

of  the  last  game  at ,  just  to  let  you  see  that  there  is 

some  life  in  the  old  dog  yet.     Since  our  game  Mr.  

won  the  club  championship  of  the  . 

"I  keep  very  well,  as  you  may  surmise  from  the  above, 
sugar-free  all  the  time.  I  stick  to  the  same  old  routine — 
30  to  31  grams  carbohydrate  per  diem.  I  gave  up  the  orange, 
as  I  really  prefer  the  5  per  cent,  vegetables,  and  I  thought 
that  I  took  the  vegetables  better.  I  had  a  fine  five  days 
the  end  of  September,  up  in  the  woods,  trout-fishing;  had 
good  weather  and  very  good  fishing.  I  managed  to  keep 
sugar-free  all  the  time,  although  I  had  a  good  appetite  and 
took  lots  to  eat." 

February,  1918,  the  patient  continued  in  good  condition, 
sugar-free,  with  tolerance  as  before. 

Explanation  of  the  General  Peinciples  Underlying 
THE  Treatment  of  Moderately  Severe  and  Severe 
Cases  of  Diabetes. — It  has  been  shown  that  there  are  many 
means  by  which  the  urine  of  a  diabetic  patient  may  be  freed 
from  sugar,  but  the  simplest  of  all  is  by  fasting,  and  to  this 
all  other  methods  converge.  If  fasting  for  a  day  or  two 
appears  inadvisable,  the  simple  omission  of  fat,  which  mate- 


94  DIETETIC  TREATMENT  OF  DIABETES 

rially  reduces  the  nutritive  value  of  the  diet,  may  render 
the  patient  sugar-free.  Formerly,  physicians  endeavored 
to  get  their  patients  sugar-free  by  the  reduction  of  carbo- 
hydrate in  the  diet,  at  the  same  time  immediately  increasing 
the  fat  and  protein  to  make  up  for  the  calories  thus  lost. 
Various  dangers  attended  this  practice,  and  at  present  it  is 
generally  abandoned.  The  method  now  adopted  to  free  the 
urine  of  sugar  is  designed  to  accomplish  this  end  without 
any  risk  to  the  patient.  It  is  brought  about  either  by  com- 
plete fasting  or  by  the  withdrawal  of  fat  from  the  diet,  and 
the  subsequent  reduction  of  carbohydrate  and  protein  to  a 
point  at  which  the  patient  no  longer  voids  sugar  in  the  urine. 
Frequently  both  methods  are  combined,  for  it  frequently 
happens  that  by  the  adoption  of  the  plan  about  to  be 
described  under  "Preparation  for  Fasting"  that  a  patient 
becomes  sugar-free  within  a  few  days  and  free  from  acid 
poisoning  if  that  were  present.  By  methods  like  the  above 
alkalis  are  unnecessary,  and,  indeed,  I  believe  if  they  are 
given  that  they  do  harm.  In  the  following  paragraphs  in 
italics  the  plan  is  summarized: 

Preparation  for  Fasting.  —  In  severe,  long-standing, 
complicated,  obese  and  elderly  cases,  as  icell  as  in  all  cases 
with  acidosis,  or  in  any  case  if  desired,  icithout  otherwise 
changing  habits  or  diet,  omit  fat,  after  two  days  decrease  protein 
and  halve  the  carbohydrate  daily  until  the  patient  is  taking  SO 
grams  or  less;  then  fast.     In  other  cases  begin  fasting  at  once. 

Fasting. — Fast  four  days,  unless  earlier  sugar-free.  Allow 
water  freely,  tea,  coffee  and  thin,  clear  meat  broths  as  desired. 

It  is  important  for  the  patient  to  observe  how  his  physician 
frees  the  urine  from  sugar  in  his  particular  case,  because 
later  if  sugar  should  return  he  could  follow  the  same  plan 
by  himself. 

Table  29  shows  how  Case  No.  938,  a  child,  aged  two  years 
and  four  months,  became  sugar-free  in  two  days  with  a 
moderately  restricted  diet  for  the  first  day  and  with  fasting 
for  the  second  day. 

It  will  be  observed  that  diacetic  acid  appeared  October 
26  and  27.  In  1915  the  necessity  of  completely  omitting  fat 
prior  to  fasting  was  not  appreciated.    With  present  methods 


DIETETIC  TREATMENT  OF  DIABETES 


95 


of  treatment  this  appearance  of  diacetic  acid  would  not  occur, 
because  during  the  last  two  years  measures  taken  for  the 
safety  of  the  patient  at  the  beginning  of  treatment  have 
increased  enormously. 

Table  29.— Case  No.  938.     Aged  Two  Years,  Four  Months. 
Onset  September,  1915. 


Date. 

Urine. 

Diet 

Diacetic  acid. 

Sugar,  per  cent. 

1915. 
October  25 
October  25-26 
October  26-27 

0 
0 

+ 

7.6 

3.2 

0 

Diet  unrestricted. 

Diet  moderately  restricted. 

Fasting. 

Case  No.  979,  a  woman,  aged  forty-nine  years,  developed 
diabetes  at  the  age  of  thirty-two.  When  she  was  first  seen 
seventeen  years  later,  January  26,  1916,  she  showed  7.4 
per  cent,  of  sugar  and  no  diacetic  acid.  It  is  apparent  from 
Table  30  how  she  became  sugar-free  without  the  develop- 
ment of  acidosis  by  the  elimination  of  fat  and  the  restriction 
of  protein,  followed  by  the  gradual  diminution  of  carbo- 
hydrate. 

Table  30. — Case  No.  979,  of  Seventeen  Years'  Duration,  Illus- 
trates (1)  How  Preparatory  Treatment  Makes  Fasting 
Unnecessary  and  (2)  Renders  the  Urine  Sugar-free 
without  the  appearance  of  acid  poisoning. 


Urine. 

Diet  in  grams. 

Dietary  prescriptions  in  grams. 

Sugar. 

t5 

(U 

-o 

+3 

Date,  1916. 

c3 

^ 

0 

-  c 

■3 

fl 

f-> 

Xi 

d 

.tT 

X3    IH 

•ii 

9 

?\ 

g 

I 

o 

S 

^ 

M 

%^ 

a 

13 

(fl 

■0 

03 

"a 

"S 

(U 

ci 

Q 

H 

O 

P-( 

0 

^ 

> 

0 

0 

PL| 

PQ 

<1 

§ 

0 

(^ 

Jan.        25 

0 

7.4 

25-26 

0 

6.2 

54 

180 

26-27 

0 

^.P, 

83 

142 

48 

16 

944 

128 

300 

1 

1.0 

90 

100 

1    90 

6 

27-28 

0 

4.0 

70 

112143 

16.764 

128 

300 

1 

1.0 

90 

50 

1     90 

6 

28-29 

0 

2.2 

26 

72i38 

16   584 

128 

300 

1 

2.0   90 

0 

0     90 

6 

29-30 

0 

1   0 

14 

50 

28 

111  411 

127 

300 

1 

1.0   30 

0 

0     601  6 

30-31 

0 

0.6 

8 

40 

28 

111371 

127 

300  !   1 

0.0   30 

0 

0     60    6 

Feb.  31-  1 

0 

0.2 

2 

25 

26 

5:249 

126 

300     0 

0.5,30 

0 

0     20    6     40 

1-  2 

0 

0.0 

0 

25 

27 

8 

280 

126 

300 

0 

0.5 

30 

0 

0     40    6  ,  20 

1917 

'   ^             1 

Feb.        16 

•• 

Trace 

0 

96  DIETETIC   TREATMENT  OF  DIABETES 

Fastiiifi. — Fasting  is  never  so  rigorous  as  doctors  or  j^atients 
ex})eet.  Patients  are  more  ready  to  undergo  it  than  physi- 
cians to  prescribe  it.  Quite  as  often  it  is  as  much  a  relief 
to  the  patient  as  it  is  discomfort.  This  is  in  part  due  to  the 
gradual  decrease  in  thirst  and  frequent  urination.  Headache 
occurs  less  frequently  than  Avould  be  expected,  and  is  usually 
dispelled  by  a  cup  of  coft'ee.  Nausea  almost  never  occurs 
unless  a  patient  is  given  alkali  or  alcohol.  Children  bear 
fasting  more  easily  than  adults.  Case  No.  899,  with  onset 
at  eighty-three,  shunned  it  and  rightly,  but  she  became 
sugar-free,  and  two  years  later  was  \'igorous,  remained 
sugar-free  and  actually  able  to  eat  apple  ])ie  and  ])ut  sugar 
in  her  coffee  without  sugar  occurring  in  the  urine.  It  is. 
always  desirable  to  avoid  fasting  in  the  old,  and  this  can 
be  accomplished  usually  b\'  the  help  of  preparatory  treat- 
ment. Fasting  does  not  seem  like  fasting  to  the  patients 
when  they  recei\'e  coffee,  tea,  cracked  cocoa,  cocoa  shells 
and  broths  and  are  given  an  unlimited  supply  of  water. 
Warm  drinks  are  preferable.  If  the  quantity  of  urine,  as  it 
often  does,  falls  to  less  than  normal  the  patients  are  urged 
to  drink  water  freely.  Clear  meat  broths  are  a  great  satis- 
faction. An  analysis  of  the  1220  c.c.  of  broths  taken  by 
Case  No.  765  diu-ing  three  days  showed  the  total  amount 
of  calories  therein  contained  to  be  negligible.  Contrary  to 
my  experience  with  digestive  cases,  broths  do  not  stimulate 
the  appetite  in  fasting  diabetics;  they  relieve  it.  The  advan- 
tage of  broths  is  probably  due  in  part  to  this,  but  to  a  con- 
siderable extent  to  the  patient  receiving  salt  by  which  he 
may  maintain  the  equilibriimi  of  body  fluid. 

Patients  need  not  be  kept  in  bed  during  fasting,  neither 
should  they  be  forced  to  be  up  all  day.  Reclining  in  a  steamer 
chair  requires  no  more  exertion  than  rest  in  bed.  Kemember 
what  happens  to  an  old  man  who  is  suddenly  confined  to 
bed  and  the  discomfort  which  follows  confinement  after  a 
fracture.  Do  not  force  a  temperate  man  to  drink  against 
his  will.  Patients  should  be  afforded  diversion  by  brief 
visits  from  friends,  walking  short  distances,  easy  handi- 
work, playing  games,  letter-writing  and  reading.  In  general, 
they  are  glad  to  rest  for  the  greater  part  of  the  first  day  of 


DIETETIC   TREATMENT  OF  DIABETES  97 

the  fast,  but  upon  each  succeeding  day  they  are  usually 
desirous  to  increase  the  amount  of  exercise.  An  a<lvantage 
which  the  omission  of  fat  from  the  diet  affords  is  the  rest 
which  is  given  to  the  digestive  tract.  Former  treatment, 
which  increased  the  fat  in  the  diet,  was  the  converse  of 
this,  and  frequently  led  to  vomiting,  with  the  result  that 
patients  on  the  brink  of  coma  fell  into  it.  In  every  way 
seek  to  prevent  worry  on  the  patients'  part,  and  from  the 
start  give  them  to  understand  that  they  are  at  a  school 
rather  than  at  a  hospital. 

Patients  upon  a  low  diet  should  be  guarded  from  infections. 
If  a  nurse  has  a  cold  she  should  be  relieved  from  duty,  cer- 
tainly from  duty  near  diabetics.  For  this  reason  when  on  a 
low  diet  patients  should  keep  out  of  street  cars  and  shun 
congregations  of  people. 

It  is  surprising  how  variable  is  the  period  required  to 
render  the  urine  sugar-free.  Frequently  a  urine  which  con- 
tains 7  per  cent,  of  sugar  becomes  free  from  sugar  after  fast- 
ing for  four  meals,  and,  conversely,  a  urine  with  only  3  per 
cent,  of  sugar  may  still  retain  traces  after  the  patient  has 
been  deprived  of  food  for  three  or  four  days.  These  are 
cases  with  high  percentages  of  sugar  or  fat  in  the  blood  and 
cases  of  long  duration  who  have  been  upon  a  diet  with  low 
carbohydrate  and  excessive  quantities  of  fat.  Cases  present- 
ing acidosis  invariably  require  longer  to  become  free  from 
sugar.  In  general,  cases  seen  soon  after  onset  become  sugar- 
free  promptly,  whereas  the  reverse  is  true  for  those  of  long 
duration,  though  the  latter  may  do  very  well  if  they  are 
free  from  acid  poisoning.  Case  No.  733,  age  at  onset 
seventeen  years,  was  fasted  twenty-six  months  later,  when 
he  showed  6.6  per  cent,  of  sugar  and  became  sugar-free  in 
two  days.  The  explanation  in  this  instance  was  apparently 
the  fact  that  the  case  was  remarkably  mild,  being  of  the 
obesity  type;  in  fact,  the  patient's  highest  weight — 196 
pounds — was  reached  when  he  first  came  under  observation. 
During  the  preceding  twenty-six  months  he  had  gained 
twenty-six  pounds.  Children  showing  large  amoimts  of 
sugar  have  also  become  sugar-free  very  prompth-  when  the 
duration  has  been  only  a  few  weeks.  Cases  of  long  standing 
7 


98  DIETETIC  TREATMENT  OF  DIABETES 

appear  to  become  sugar-free  more  quickly  \\\t\\  preparatory 
treatiiient  than  with  an  iimnediate  fast.  This  is  probably 
due  to  the  avoidance  of  acidosis.  Rarely  is  it  necessary 
for  a  patient  to  fast  more  than  a  few  days,  and  it  is  usually 
preferable,  after  four  days  of  fasting,  if  the  lu-ine  still  contains 
sugar  to  feed  the  patient  for  two  days  and  then  fast  again. 
The  general  rule  which  serves  as  a  guide  follows: 

Intermittent  P'asting. — 7/  glycosuria  persists  at  the  end 
of  four  days,  give  1  gram  'protein  or  0.5  gram  carbohydrate  per 
kilogram  body  weight  for  two  days  and  then  fast  again  for  three 
days  unless  earlier  sugar-free.  If  glycosuria  remains,  repeat 
and  then  fast  for  one  or  two  days  as  necessary.  If  there  is  still 
sugar,  give  protein  as  before  for  four  days,  then  fast  one  and 
then  gradually  increase  the  periods  of  feeding,  one  day  each 
time,  until  fasting  one  day  each  iceek. 

Carbohydrate  Tolerance, — Inspection  of  the  various 
charts  above  cited  will  show^  that  when  the  twenty-four  hour 
quantity  of  urine  has  been  free  from  sugar  it  is  the  custom 
to  increase  the  carbohydrate,  and  this  is  usually  done  to  the 
point  at  which  sugar  returns.  In  this  way  the  tolerance  of 
the  patient  for  carbohydrate  is  determined.  One  rule  is: 
When  the  twenty-four  hour  urine  is  free  from  sugar,  give  5  to 
10  grams  carbohydrate  {150  to  300  grams  of  5  per  cent,  vege- 
tables) and  continue  to  add  5  to  10  grams  carbohydrate  daily 
up)  to  50  grams  or  more  until  sugar  appears,  then  fast  until  sugar- 
free.  The  carbohydrate  is  generally  given  in  the  form  of  5  per 
cent,  vegetables,  choosing  those  which  are  especially  bulky.  A 
plateful  of  lettuce  appeals  much  more  to  the  patient  than  a 
small  saucer  of  string  beans.  When  a  mixture  of  5  per  cent, 
vegetables  is  given,  one  can  be  quite  sure  that  the  average 
content  of  carbohydrate  is  not  mpre  than  3  per  cent.,  or 
approximately  5  grams  for  the  150  grams  prescribed,  and 
for  convenience  this  is  reckoned  as  1  gram  of  carbohydrate 
for  each  30  grams  (1  oimce).  This  small  amount  of  food,  of 
course,  has  little  nutritive  value,  but  is  enough  to  break  the 
fast.  Upon  succeeding  days,  5,  10  or  even  more  grams  of 
carbohydrate,  ^'a^3dng  w'ith  the  severity  of  the  case,  are 
added  daily  mitil  sugar  returns  or  the  approximate  quantity 


DIETETIC   TREATMENT  OF  DIABETES  99 

is  reached  which  it  appears  probable  the  patient  will  tolerate. 
It  should  be  borne  in  mind  that  a  patient  fasting  or  on  a  very 
low  diet  often  shows  an  apparent  tolerance  for  carbohydrate 
far  in  excess  of  that  which  he  would  have  shown  if  the  neces- 
sary protein  and  fat  in  his  diet  were  simultaneously  ingested. 

Following  the  trial  with  5  per  cent,  vegetables,  one  can 
proceed  to  the  10  per  cent,  group,  and  these  can  be  empiri- 
cally reckoned  as  containing  6  per  cent,  carbohydrate  or 
approximately  twice  that  of  the  5  per  cent,  group,  or  5  grams 
carbohydrate  for  75  grams  vegetables.  From  this  point 
onward  the  addition  of  carbohydrate  can  be  made  according 
to  the  desire  of  the  patient.  The  foods  commonly  employed 
in  determining  the  tolerance  for  carbohydrate  are :  5  per 
cent,  vegetables,  oranges,  oatmeal,  Shredded  Wheat,  milk  or 
skimmed  milk  and  potato.  With  children  one  often  makes 
the  mistake  of  increasing  the  carbohydrate  too  rapidly,  for- 
getting the  fact  that  5  grams  of  carbohydrate  to  a  child  weigh- 
ing 20  kilograms  is  in  the  same  proportion  as  15  grams  of 
carbohydrate  to  an  individual  of  60  kilograms. 

The  increase  in  carbohydrate  is  also  illustrated  by  Case 
No.  1209,  Table  31,  page  101,  whose  chart  shows  how  sugar 
sometimes  appears  in  the  urine  when  if  the  doctor's  advice 
had  been  followed  it  would  have  remained  absent.  This 
little  boy  ate  candy,  and  although  the  quantity  of  sugar 
in  his  urine  had  fallen  to  1  gram  on  January  3-4,  it  re- 
quired two  days  of  fasting  following  his  use  of  candy  for  it 
to  disappear.  Later  he  broke  rules  again  and  fastmg  was 
necessary.  Gradually  he  learned  his  lesson,  at  least  tem- 
porarily, and  left  the  hospital  with  a  tolerance  for  37  grams 
of  carbohydrate  and  more  calories  than  now  would  seem  wise. 

Protein  Tolerance.— PFAe?i  the  urine  is  again  sugar-free 
decrease  the  carbohydrate  hy  two-thirds  below  the  carbohydrate 
tolerance,  or  at  least  10  grams,  and  then  add  about  20  grams 
-protein  and  thereafter  15  grams  -protein  daily  in  the  form  of 
egg-white,  fish  or  lean  meat  {chicken)  until  the  patient  is  receiv- 
ing from  1  gram  protein  to  1.5  grams  protein  per  kilogram  body 
weight. 

Thirty  grams  of  fish  or  an  eg^  of  average  size  contain 


100  DIETETIC   TREAT MEXT  OF  DIABETES 

apjiroxunately  0  gr;uiis  of  protein  and  '.]0  i^rams  of  lean  meat 
contain  approximately  S  grams.  Tlie  white  of  an  egg  con- 
tains 3  grams  of  protein.  By  this  arrangement  a  patient 
weighing  00  kilograms  wonld  be  taking,  within  fonr  days  from 
the  tijne  he  became  sugar-free,  1  gram  of  ]:)rotein  per  kilo- 
gram body  weight.  This  quantity  is  ciuite  satisfying  to  all 
except  children — in  fact,  it  is  astonishing  to  me  to  find  how 
few  patients  care  to  take  as  much  as  1.5  grams  of  protein 
per  kilogram  body  weight.  Children,  howe^■er,  crave  and 
need  considerably  more,  and  indeed  take  with  a\'idity  as 
much  as  2  to  3  grams  })rotein  per  kilogram  body  weight. 

Fish  is  especially  desirable  in  the  early  da\s  of  ])rotein 
feeding  because  it  contains  so  little  fat.  Cod,  haddock,  pike, 
skate,  pollock,  flounder  and  bass,  for  example,  contain  less 
than  1  i)cr  cent.  Blue-fish  contains  1.2  per  cent.,  smelts  1.8, 
trout  2.1  and  white  fish  and  perch  each  15  per  cent. 

The  ad^■antage  of  gi^'ing  and  increasing  protein  simul- 
taneously with  the  determination  of  the  carbohydrate 
tolerance  is  that  one  approaches  more  nearly  normal  condi- 
tions. What  the  physician  is  after  is  to  determine  the  carbo- 
hydrate tolerance  while  the  patient  is  on  a  full  diet  and  not 
the  tolerance  for  carbohydrate  alone.  On  the  other  hand  a 
higher  carbohydrate  tolerance  can  be  attained  when  the  addi- 
tion of  protein  following  the  preHminary  fasting  is  deferred 
until  the  actual  carbohydrate  tolerance  is  learned  in  the 
absence  of  protein  and  fat.  Naturally  the  method  adopted 
will  vary  somewhat  with  each  patient.  With  patients  who 
exhibit  acidosis  it  is  often  preferable  to  defer  the  addition 
of  protein  imtil  after  the  carbohydrate  tolerance  alone  has 
been  determined.     The  carbohydrate  dispels  the  acidosis. 

There  are  very  few  patients  who  will  not  bear  at  the  outset 
as  much  as  1  gram  of  protein  per  kilogram  body  weight.  It 
is  unfortunate  to  allow  the  protein  to  remain  permanently 
below  this  figm-e.  This  can  be  avoided  by  still  further 
restricting  the  carbohydrate,  either  temporarily  or  per- 
manenth'.  It  is  always  necessary  to  remember  that  one 
food  which  the  diabetic  patient  cannot  do  without  is  protein, 
and  to  it  everything  else  must  be  subordinated.  ]\Iore  and 
more^^an  effort  should  be  made  to  spare  body  protein, 


DIETETIC  TREATMENT  OF  DIABETES 


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102  DIETETIC   TREATMENT  OF  DIABETES 

Fat  Tolerance. — The  studies  of  Professor  Bloor  and 
Dr.  Gray  in  Boston  and  that  of  workers  at  \arioiis  other 
hiboratories  has  provided  us  with  a  rehable  indicator  for 
the  tolerance  of  the  j^atient  for  fat  by  means  of  the  esti- 
mation of  fat  in  the  blood.  As  yet  the  test  is  too  compli- 
cated for  general  use,  but  for  those  who  have  access  to  a 
laboratory  it  is  perfectly  practical.  For  those  not  in  a 
position  to  employ  Bloor's  fat  method  there  are  indirect 
methods  of  determinhig  fat  tolerance,  namely,  signs  of 
acidosis  and  the  appearance  of  sugar  in  the  urine  (glyco- 
suria) or  an  increase  of  sugar  in  the  blood.  So  long  as 
these  exist  the  fat  must  be  kept  low.  While  testing  the 
protein  tolerance  a  small  quantity  of  fat  is  included  if, 
in  addition  to  whites  of  eggs  and  lean  fish,  meat  is  given. 
Formerly  this  appeared  advantageous,  and  such  small 
quantities  of  fat  certainly  do  no  harm  in  the  milder  cases. 
In  fact,  the  same  rule  holds  for  the  testing  of  the  carbohydrate 
and  protein  tolerance  in  the  presence  of  fat  as  has  been  said 
for  protein  alone.  There  are,  on  the  other  hand,  two  impor- 
tant reasons  why  fat  should  not  be  given  to  the  diabetic 
patient  inmiediately  upon  his  becoming  sugar-free:  (1)  by  the 
omission  of  fat,  partial  fasting  is  continued  and  thereby 
the  patient  is  gainmg  a  tolerance  for  carbohydrate,  and  (2) 
the  continued  omission  of  fat  is  beneficial  in  counteracting  the 
last  vestige  of  acid  poisoning,  or  preventing  the  appear- 
ance of  acid  poisoning,  which  might  easily  occur  in  a  diabetic 
patient  whose  metabolism  has  not  become  accustomed  to  so 
low  a  quantity  of  carbohydrate.  But  as  soon  as  the  patient 
has  received  the  essential  gram  of  protein  per  kilogram 
body  weight  and  the  blood  sugar  has  reached  normal  the 
fat  in  the  diet  should  be  increased.  If  the  patient  is  one 
in  whom  acidosis  has  been  an  essential  factor,  or  if  the 
patient  is  obese,  the  fat  should  be  increased  slowly,  and  for 
such  a  patient  an  increase  of  5  to  10  grams  a  day  may 
be  all  that  he  can  take  without  the  recm-rence  of  a  posi- 
tive ferric  chloride  reaction  in  the  urine.  Cases  which  have 
shown  little  acidosis  may  easily  be  allowed  an  increase  of 
15  grams  fat  daily,  and  for  such  cases  this  is  desirable, 
because  it  rapidly  brings  the  total  caloric  value  of  the  diet 


DIETETIC  TREATMENT  OF  DIABETES  103 

up  to  a  normal  figure.    Natiu*ally,  patients  in  whose  treat- 
ment a  loss  of  weight  is  desired  would  be  given  smaller 
quantities  of  fat. 
A  working  rule  is  as  follows: 

Fat  Tolerance. — It  is  usually  desirable,  especially  in  the 
young,  to  add  no  fat  until  the  jnotein  reaches  1  fjram  to  1.5 
grams  protein  per  kilogram  body  weight  and  the  blood  sugar  is 
normal.  Then  add  5  to  25  grams  daily,  according  to  previous 
acidosis,  until  the  patient  ceases  to  lose  weight  or  receives  in  the 
total  diet  20  to  30  calories  per  kilogram  body  loeight. 

Reappearance  of  Sugar. — The  return  of  sugar  demands 
fasting  for  twenty-four  hours  or  until  sugar-free.  Resume  the 
former  diet,  adding  fat  gradually,  and  last  of  all  in  order  to 
maintain  as  high  a  carbohydrate  tolerance  as  possible,  sacrificing 
body  weight  for  this  purpose.  This  rule  should  be  inflexibly 
followed,  especially  with  children. 

In  hospitals  the  above  rule  simplifies  the  treatment  enor- 
mously. As  soon  as  it  is  understood  that  the  reappearance 
of  sugar  means  a  fast  until  sugar  disappears  from  the  twenty- 
four  hour  quantity  of  urine  there  is  little  tendency  to  break 
over  the  diet.  Furthermore,  most  patients  are  thrifty  enough 
to  see  the  disadvantage  of  paying  their  board  with  no  return. 
The  rule  must  be  rigidly  enforced  with  children,  because 
with  them  disobedience  means  death.  When  a  patient  has 
been  made  sugar-free  by  a  preliminary  fast,  absence  of  food 
for  twenty-four  hours  will  almost  invariably  be  sufficient 
to  free  the  urine  at  once  if  the  sugar  returns.  This  will  not 
be  the  case  unless  the  presence  of  glucose  is  promptly  detected 
and  hence  the  necessity  for  the  patient  to  examine  his  twenty- 
four  hour  urine  daily.  Following  this  accessory  fasting  day, 
the  previous  diet  of  the  patient  may  be  gradually  resumed, 
making  every  endeavor  to  regain  the  former  tolerance  for 
carbohydrate  by  slowly  increasing  the  quantity  of  fat. 
Great  care  should  be  exercised,  more  indeed  than  has  been 
often  taken,  not  to  break  down  the  tolerance  a  second  time. 
Months  rather  than  weeks  should  intervene  before  the 
final  amounts  of  carbohydrate,  protein  and  fat,  reached  the 
second  time,  equal  the  quantity  of  carbohydi-ate,  protein  and 
fat  eaten  when  sugar  reappeared. 


10-1  DIETETIC   TREAT ME.\T  OF  DIABETES 

ratieiits  often  get  into  trouble  by  their  failure  to  energeti- 
cally gTap])le  with  the  reappearance  of  sugar.  One  day  of 
fasting  will  accomplish  far  more  than  many  days  of  a  moder- 
ately low  diet.  It  is  a  mistake  for  any,  save  the  most  highly 
trained  patients,  to  attempt  to  meet  such  a  situation  without 
medical  advice. 

Case  No.  804,  described  on  page  90,  illustrates  this  well, 
for  it  is  perfectly  evident  that  he  was  an  intelligent  patient, 
and  yet  grew  steadily  worse  until  he  returned  for  the  second 
period  of  treatment  at  the  hospital. 

Another  instance  is  Case  No.  1279,  who  reached  a  toler- 
ance in  April,  1917,  for  78  grams  carbohydrate,  63  gi*ams  pro- 
tein and  109  grams  fat,  with  a  blood  sugar  at  this  tune  of 
0.12  per  cent.  In  the  autmnn  of  the  same  year  sugar  repeat- 
edly reciu"red  and  he  was  unable  to  become  sugar-free  at 
home.  After  a  stay  of  a  few  weeks  at  the  hospital  he  was 
discharged  Avith  a  tolerance  for  65  grams  carbohydrate,  74 
grams  ])rotein,  98  grams  fat  and  blood  sugar  of  0.14  per  cent. 

Still  another  ])atient,  Case  No.  1265,  shows  the  miprove- 
ment  of  medical  supervision.  This  patient,  a  woman,  aged 
fifty-seven  years,  left  the  Corey  Hill  Hospital  on  IMay  5, 
1917,  with  a  tolerance  for  30  grams  carbohydrate,  58  gi-ams 
protein  and  119  grams  fat,  with  a  blood  sugar  under  0.10 
per  cent.  Intil  the  summer  she  did  well,  but  in  the  early 
autmnn,  apparently  finding  the  urine  normal,  she  steadily 
increased  her  diet,  yet  her  condition  was  not  satisfactory 
to  herself  or  her  friends.  Upon  the  return  of  her  doctor  he 
discovered  that  the  Benedict  solution  she  had  been  using 
was  inaccurately  made  up  and  for  over  a  month  sugar  had 
undoubtedly  been  present  in  the  urine.  Under  hospital 
treatment  she  was  discharged  in  two  weeks,  with  a  tolerance 
for  33  grams  carbohydrate,  61  grams  protein  and  81  grams 
fat,  with  a  blood  sugar  of  0.14  per  cent. 

Weekly  Fast  Days.  —  Whether  sugar  reaypears  in  the 
urine  or  not  it  is  desirable  upon  one  day  each  week  to  rest  that 
function  of  the  body  tchich  controls  the  assimilation  of  sugar 
by  either  a  complete  fast  day  or  a  diet  of  low  caloric  value. 

The  folloiving  rule  is  suggested:  Whenever  the  tolerance 
is  less  than  20  grams  carbohydrate,  fasting  should  be  practised 


DIETETIC  TREATMENT  OF  DIABETES  105 

07ie  day  in  seven;  when  the  tolerance  is  over  20  (jranis  carbo- 
hydrate, cut  the  diet  in  half  on  one  day  each  week  {"half-day"). 
This  is  the  revival  of  an  old  practice  used  many  years  ago, . 
I  understand,  by  Dr.  Austin  Flint,  of  New  York,  who  kept 
in  bed  and  fasted  his  diabetic  patients  on  Sundays.  Von 
Noorden  terms  such  weekly  fast  days  "Diabetic  Sundays." 

The  benefit  which  the  older  clinicians  derived  from  the 
use  of  one  day's  fast  in  seven  in  the  treatment  of  their 
diabetic  patients  should  ever  be  borne  in  mind.  Case  No. 
1062,  now  under  observation,  who  contracted  diabetes  twenty- 
six  years  ago,  possibly  in  connection  with  gall-stones,  tells 
me  that  at  that  period  her  physician,  Dr.  Randall,  of 
Topsfield,  Mass.,  often  told  her  to  go  without  food,  save 
broths,  for  several  days  in  succession,  and  that  she  was 
accustomed  to  follow  this  advice.  Her  severe  symptoms  of 
diabetes  subsided  at  the  end  of  four  years.  Recently  the 
quantity  of  sugar  has  been  slight.  Her  tolerance  on  June  1, 
1916,  reached  116  grams  carbohydrate.  The  advantage 
of  this  restricted  diet  day  each  week  is  partly  inlierent  in 
the  fast  or  restricted  diet,  but  to  a  considerable  extent  it  is 
due  to  the  attention  of  the  patient  being  sharply  called  to 
his  disease  one  day  in  seven,  and  the  recollection  which  it 
awakens  in  his  mind  of  his  condition  before  treatment  began 
and  the  difficulties  which  may  have  originally  accompanied 
becoming  sugar-free.  Some  exceptions  to  the  above  rules 
may  be  mentioned :  for  example,  elderly  patients  bear  fasting 
poorly,  and  when  they  remain  sugar-free  upon  a  rigid  diet 
containing  only  10  grams  of  carbohydrate  it  is  my  impression 
that  it  is  better  to  sunply  restrict  the  calories  of  the  diet 
one-half  on  one  day  each  week  rather  than  to  institute  an 
absolute  fast.  With  such  treatment  these  patients  almost 
invariably  gain  in  tolerance  for  carbohydrate.  Children 
become  fretful  upon  a  fast  day,  though  physically  they 
endure  it  well.  If  they  are  allowed  a  few  green  vegetables  in 
addition  to  broths  they  get  along  very  comfortabl}\  Von 
Noorden  pointed  out  that  the  good  effects  of  a  fast  day 
continued  many  days  beyond  the  actual  fast. 

The  Caloric  Needs  of  the  Patient. — The  total  nmnber  of 
calories  which  a  diabetic  requires  varies  not  only  with  each 


106  DIETETIC  TREATMENT  OF  DIABETES 

case^  but  varies  with  each  ease  each  day.  Schematic  rules 
do  not  hold.  One  must  remember  that  an  individual  trained 
to  be  quiet,  and  while  lying  down  can  get  along  with  only 
20  calories  per  kilogram  body  weiglit  reckoned  jier  twenty- 
four  hours,  whereas  the  average  ot"  a  large  group  of  normal 
men  and  women  at  the  Nutrition  Laboratory,  not  especially 
trained  for  the  test,  consimied  25  calories  per  kilogram  body 
weight  reckoned  also  per  twenty-four  hours.  If  this  varia- 
tion exists  while  at  rest,  how  much  more  it  must  exist  during 
the  various  activities  of  different  individuals.  Furthermore, 
one  must  remember  that  the  number  of  calories  consmned 
per  hoiu"  varies  enormously.  An  individual  weighing  60 
kilos  walking  at  the  rate  of  four  miles  per  hour  would  require 
an  additional  193  calorics  for  that  hour  over  the  resting 
metabolism.  Habits  of  mdividuals  vary  widely.  Some  are 
quiet  and  some  are  active.  All  these  considerations  should 
be  clearly  borne  in  mind  by  doctors  and  patients  in  order 
not  to  allow  themselves  to  be  held  too  rigidly  by  any  caloric 
fetish. 

Special  Dietetic  Rules  and  Hints. — The  responsibility  for 
the  management  of  the  diet  of  a  diabetic  patient  should 
always  rest  upon  one  individual.  As  a  rule  that  individual 
is  the  patient,  but  at  times  another  member  of  the  house- 
hold.- Children  who  are  above  the  age  of  ten  years  should 
be  taught  to  plan  their  ovm  diet.  They  readily  learn  to  do 
this,  and  in  so  doing  make  their  elders  blush.  In  fact,  it  is 
more  important  for  diabetic  children  to  learn  what  and  how 
much  to  eat  than  all  the  knowledge  which  their  schools 
afford,  for  upon  this  information  their  life  depends.  Perhaps 
it  is  because  this  personal  responsibility  is  so  deeply  felt  in 
the  management  of  little  children  that  the  treatment  of 
diabetes  in  them  proceeds  so  uniformly  and  always  produces 
results  so  much  better  than  are  expected. 

Patients  should  eat  too  little  rather  than  too  much.  With 
a  return  to  normal  weight  sugar  may  appear. 

All  food  should  be  eaten  slowly,  and  the  coarser  the  food 
the  more  thoroughly  it  should  be  masticated. 

If  in  doubt  about  a  food,  let  it  alone  until  you  have  found 
out  whether  it  is  allowed.     Do  not  yield  to  the  tempta- 


DIETETIC  TREATMENT  OF  DIABETES  107 

tion  of  friends  to  break  the  diet,  for  if  this  is  done  the  plan 
of  treatment  is  upset,  a  week's  time  may  be  lost  and  several 
pounds  of  weight  sacrificed.  So-called  diabetic  foods  often 
contain  considerable  quantities  of  carbohydrate,  and  usually 
contain  so  much  protein  and  fat  tliat  they  should  not  be 
taken  by  the  patient  without  due  allowance  for  the  same. 
They  should  not  be  taken  under  any  circumstances  unless 
their  composition  is  known.  Be  especially  careful  to  note 
the  effect  of  any  increase  in  carbohydrate.  The  same  rules 
hold  for  protein.  The  quantity  of  fat  is  regulated  by  many 
factors,  among  which  are  the  presence  or  absence  of  acid 
poisoning,  the  sugar  and  fat  in  the  blood  and  by  the  patient's 
weight. 

The  carbohydrate  in  the  diet  should  be  divided  between 
the  three  meals.  Even  if  the  10  per  cent.,  15  per  cent,  and 
20  per  cent,  vegetables  are  allowed,  vegetables  from  the  5 
per  cent,  group  should  be  taken  as  well.  Usually  it  is  allow- 
able to  substitute  'for  a  given  quantity  of  5  per  cent,  vege- 
tables one-half  as  much  from  the  10  per  cent,  group,  one- 
quarter  as  much  from  the  15  per  cent,  or  one-sixth  as  much 
from  the  20  per  cent.  Exchange  vegetables  for  fruit  only 
under  advice.  Remember  it  is  always  possible  to  get  articles 
of  food  which  are  included  in  a  strict  diabetic  diet  for  a  few 
meals,  such  as  eggs,  meat,  butter,  oil  and  even  5  per  cent, 
vegetables,  fresh  or  canned.  One  of  my  cases  who"  has  done 
exceptionally  well  has  a  diabetic  garden  and  thus  provides 
liberally  for  his  table  both  summer  and  winter.  Quiet  out- 
door work  agrees  with  diabetic  patients. 

In  case  of  illness  curtail  the  fat  in  the  diet,  and  if  acid 
poisoning  is  shown  by  the  ferric  chloride  reaction,  omit  fat 
entirely. 


CHAPTER  X. 

ACID  INTOXK^ATION— ACIDOSIS— DIABETIC 
COMA. 

Acid  intoxication  is  the  bugbear  of  doctor  and  patient. 
Formerly  more  than  six  of  every  ten  diabetic  patients  suc- 
cumbed to  it;  but  now  it  is  much  less  frequent.  The  acid 
intoxication  (acid  poisoning  or  technically  termed  acidosis) 
in  diabetic  patients  differs  in  no  respect  from  the  acidosis 
which  occasionall}^  occurs  in  normal  individuals  when  car- 
bohydrate is  omitted  from  the  diet  for  three  or  four  days. 
The  ferric  chloride  (diacetic  acid)  reaction  will  then  appear 
just  as  in  a  severe  diabetic,  and  if  at  the  same  time  the 
quantity  of  fat  is  increased  a  type  of  acidosis  will  be  caused 
so  severe  as  to  threaten  the  life  of  the  individual.  When, 
however,  the  healthy  body  is  gradually  accustomed  to  live 
upon  a  diet  low  in  carboh^'drate,  acidosis  is  avoided.  The 
same  coiu-se  of  events  takes  place  in  diabetes.  In  severe 
cases  when  all  the  carbohydrate  of  the  diet  appears  in  the 
urine  as  sugar  the  diabetic  patient,  although  eating  carbo- 
hydrate, is  exactly  like  the  normal  individual  deprived  of 
his  customary  carbohydrate.  If  fat  in  undue  quantities  is 
given  to  a  severe  case  of  diabetes,  under  these  circumstances 
diabetic  coma  may  result.  This  did  result  when,  j^ears  ago, 
we  physicians,  doing  the  best  we  knew,  deprived  patients 
of  their  carbohydrates  in  order  to  make  them  sugar-free, 
and  at  the  same  time,  in  order  to  enable  them  to  maintain 
their  weight,  we  markedly  increased  fat  and  protein  to 
make  up  the  calories  omitted  as  carbohydrate.  From 
what  has  already  been  written  it  can  be  seen  how  disastrous 
this  was. 

Today  patients  on  beginning  treatment  are  first  of  all 
deprived  of  fat,  without  other  change  in  their  dietary  habits, 
(108) 


ACID  INTOXICATION— ACIDOSIS— DIABETIC  COMA     109 

in  order  to  take  away  the  great  danger  of  acid  intoxication, 
and  they  subsequently  are  either  made  sugar-free  by  gradual 
reduction  of  carbohydrate  and  protein  or  simply  by  fasting. 
When  the  patient  is  sugar-free  and  one  begins  to  increase 
the  diet  the  fat  is  the  food  element  to  be  added  last  of  all. 
Even  when  patients  already  showing  acidosis  come  for 
treatment  it  usually  disappears  under  the  above  plan. 
Should  the  acidosis  be  severe  the  following  rules  now  in 
force  for  my  cases  at  the  New  England  Deaconess  and 
Corey  Hill  Hospitals  are  suggested.  It  is  desirable  that  all 
patients  become  familiar  with  these  rules,  and  thus  anxiety 
over  acid  poisoning  will  disappear.  This  plan  of  treatment 
seldom  fails.  (See  Table  3,  p.  24.)  Indeed,  since  it  has 
been  established,  as  a  routine  method  of  procedure,  worry 
about  acid  poisoning  of  patients  has  largely  decreased,  and 
evening  visits  to  the  hospitals  can  be  eliminated. 

Rules  for  the  Treatment  of  Severe  Acid  Intoxication. 

1.  Nursing. — Provide  a  special  nurse  for  the  patient  for 
both  day  and  night,  and  preferably  one  trained  in  diabetic 
work. 

2.  Bed. — Keep  the  patient  in  bed  and  warm.  Avoid  loss 
of  calories  through  exertion  or  exposure;  if  restless,  protect 
from  the  cold  by  the  use  of  flannel  nightclothes.  Every  effort 
should  be  made  to  allay  nervousness  and  discomfort. 

3.  Care  of  the  Bowels. — Move  the  bowels  by  one  or  more 
enemata.  Cathartics  should  usually  be  avoided  for  fear  of 
causing  diarrhea. 

4.  Administration  of  Liquids. — Give  1000  c.c.  (1  quart)  of 
liquids  within  each  six  hours.  The  liquids  are  to  be  given 
slowly,  and  hot.  Use  coffee,  tea,  thin  broths,  water;  see 
also  5.  If  the  prospect  is  dubious  of  giving  so  much  liquid 
by  mouth,  salt  solution  or  tap  water  is  to  be  given  by  rectum; 
if  this  resource  fails  the  nurse  should  call  the  doctor  to  give 
intravenously,  or  if  that  is  impossible,  subcutaneously,  the 
balance  of  the  liter  which  remains  not  given  for  the  six-horn- 
period.  It  will  seldom  be  found  necessary  to  give  more  than 
IQOO  c.c.  liquids,  thanks  to  the  avoidance  of  alkalis.    In  order 


no     ACID  INTOXICATION— ACIDOSIS— DIABETIC  COMA 

to  secure  the  introduction  of  sufficient  liquid  in  the  first  six 
hours  the  cleansing  enema  at  the  beginning  of  treatment 
should  be  follo^ved  after  half  an  hour  by  an  enema  of  500  c.c. 
salt  solution  (one  teasi)oonful  of  salt  in  one  pint  of  water)  in 
all  cases  as  a  matter  of  precaution.  The  use  of  the  duodenal 
tube  may  be  helpful  in  introducing  fluid. 

5.  Diet. — ^If  the  patient  has  been  accustomed  to  the 
fasting  method  of  treatment  (a)  begin  or  continue  the  fast, 
but  (6)  if  he  has  been  upon  a  full,  unregulated  diet  omit  the 
fat  which  it  contained,  but  continue  the  approximate  quan- 
tity of  carbohydrate  and  protein  of  the  preceding  days. 
The  carbohydrate  should  be  given  in  a  form  easily  tolerated 
by  the  stomach,  such  as  carefulh'  made  gruels,  orange  juice, 
skimmed  milk,  shredded  wheat  or  bread.  Avoid  an  excess 
of  coarse  vegetables.^  The  patient  should  receive  from  10  to 
20  grams  (1  to  4  teaspoonfuls)  of  salt  daily. 

6.  Stomach. — If  there  is  evidence  of  retained  food  in 
the  stomach  or  of  a  dilated  stomach  the  stomach  should 
be  emptied  at  once.  The  prompt  recognition  of  such  a 
state  and  its  relief  will  undoubtedly  save  many  lives.  With 
adults  when  in  doubt,  but  with  children  in  all  cases,  begin 
treatment  for  threatened  coma  with  gastric  lavage. 

7.  Heart. — Sustain  the  circulation  with  the  help  of 
digitalis.  Caffein  may  be  given  subcutaneously  or  as  black 
coffee  by  the  rectum  in  addition  to  coft'ee  by  the  mouth. 

8.  Alkalis. — Avoid  alkalis.  If  such  have  been  previously 
given,  omit  at  the  rate  of  30  grams  a  day. 

1  Test  diets  Nos.  3,  4  and  5  may  be  easily  modified  to  meet  these  require- 
ments.    (See  page  89.) 


CHAPTER  XL 
WEIGHT  PECULIARITIES. 

Most  diabetic  patients  are  obese  prior  to  the  onset  of 
diabetes.  As  soon,  however,  as  sugar  begins  to  be  lost  in  the 
urine  the  weight  usually  falls  because  the  body  is  unable 
to  utilize  the  food  eaten.  It  is  not  uncommon  for  a  patient 
to  lose  50  pounds  before  treatment  begins,  and  occasionally 
a  patient  will  lose  as  much  as  100  pounds  during  the  course 
of  years.  A  diabetic  patient  in  reality  is  probably  in  safer 
condition  if  he  is  10  to  20  per  cent,  below  weight,  because 
thus  he  can  be  assured  that  he  is  not  overeating.  In  this 
respect  it  is  better  to  emulate  the  Indian  than  the  Eskimo. 
The  individual  10  per  cent,  and  even  20  per  cent,  below  weight 
may  not  be  a  delight  to  our  eyes,  but  if  over  thirty-five  years 
of  age  and  in  this  condition  he  is  much  more  acceptable  to 
the  Insurance  Company.  It  is  often  desirable  for  a  patient 
to  lose  weight,  but  this  should  be  undertaken  only  under 
the  doctor's  direction.  Frequently  it  is  only  by  losing  weight 
that  a  patient  regains  the  power  to  tolerate  carbohydrate. 
As  a  guide  to  the  proper  weight  for  a  diabetic  the  a^'erage 
weights  of  individuals  for  given  heights  and  weights  when 
dressed  are  given  in  Tables  33  to  37. 

Changes  in  Weight  during  Treatment. — Diabetic  patients 
are  often  surprised  at  the  sudden  change  in  weight  which 
they  undergo  during  a  two  weeks'  course  of  treatment. 
Occasionally  the  weight  goes  up,  but  more  often  it  falls. 
It  may  remain  the  same  or  even  increase  during  several 
days  of  fasting.  The  reason  for  these  changes  is  to  'be 
explained  by  the  retention  or  discharge  of  water  from  the 
tissues.  The  following  experiment  conducted  by  me  many 
years  ago  illustrates  this  well:  A  student  was  given  a  diet 
sufiicient  to  maintain  his  body  weight  so  far  as  nutritive 

(111) 


112 


WEIGHT  PECULIARITIES 


viihi^  was  concerned,  but  from  his  food  salt  was  entirely 
^eIno^■ed.  As  a  result,  in  the  course  of  thirteen  days  the 
weight  fell  11 .66  pounds.  Upon  the  resumption  of  his  former 
diet  with  salt  as  desired,  9  pounds  of  those  lost  were  regained 
hi  three  days.  Diabetic  ])atients  often  gain  weight  from 
exactly  the  same  cause — namely,  the  ingestion  of  too  much 
salt.  Such  gain  in  weight,  however,  should  be  looked  upon 
at  its  real  value,  in  other  words,  simply  as  a  retention  of 
fluid  in  the  body. 

Case  No.  1378,  showhig  considerable  dropsy,  lost  weight  as 
shown  in  Table  32.  When  the  equivalent  of  the  weight  lost 
was  weighed  out  in  water  it  half-filled  a  pail,  and  when  we 
realized  that  this  had  been  carried  about  all  day  in  the 
tissues  of  the  patient,  all  of  us  were  far  more  sympathetic 
toward  the  patient's  disinclination  to  go  up  and  down  stairs. 


Table  32. — Chaet  of  Case  No.  1378.    Illustration  of  Dlsappear- 

ANCE  OF  Dropsy  Co-existent  with  Loss  of  Weight 

Due  to  a  Salt-free  Diet. 


Urine. 

Diet  in  grams. 

Date, 
1917. 

Di- 
acetic 
acid. 

NaCl    ^ugar 
^^^''  ■  tota 
^■•a'"^-  1  grams 

Carbo- 
hydrate 

Pro- 
tein. 

Pat. 

Alcohol. 

Calories. 

Weight, 
lbs. 

Sept.  13-14 

23-24 

Oct.    21-22 

i 
0 

0        4.9 
0 

0 
6 
0 

3 
17 
12 

20 
50 
53 

6 
42 
52 

■50' 
30 

146 
996 
938 

891 
98i 
69  J 

Soon  after  entrance  the  salt  in  the  diet  was  partially 
restricted,  but  evidently  not  enough  to  prevent  increase  in 
weight,  as  the  chart  shows  (see  September  23-24).  From 
this  point  onward  the  salt  was  excluded  with  the  greatest 
care  from  the  diet,  and  the  weight  uniformly  fell.  It  is  note- 
worthy that  this  patient  a  year  previously,  some  thousands 
of  miles  from  Boston,  had  been  given  during  a  period  of  six 
months  enemata  of  8  quarts  of  salt  and  soda  daily.  Further- 
more, she  was  then  in  the  habit  of  taking  beef  tea  loaded 
with  salt,  and  each  week  consmned  one  and  a  lialf  pounds 
of  salted  almonds,  as  well  as  using  salt  freely  in  her  food. 


CHANGES  IN  WEIGHT  DURING  TREATMENT     113 


Table  33. 

, — Heights  and 

Weights  of  Chil 

DREN  BETWEEN  OnE  / 

Four  Years 

OF  Age  (Withou' 

r  Clothes). 

■ 4821  girls 

Height, 
inches. 

Height, 
inches. 

ooU-i  Doys 

Weight, 
pounds. 

Age, 
months. 

Weight, 
pounds. 

26.5 

18.0 

6 

25.9 

16.8 

27.3 

19.1 

7 

26.5 

17.4 

27.6 

19.8 

8 

27.0 

18.3 

28.1 

20.4 

9 

27.6 

19.1 

28.5 

20.9 

10 

27.9 

19.5 

29.0 

21.4 

11 

28.4 

20.1 

29.4 

21.9 

12 

28.9 

20.8 

29.9 

22.9 

13 

29.4 

21.0 

30.3 

23.0 

14 

29.5 

21.6 

30.8 

23.6 

15 

30.1 

21.9 

31.1 

24.1 

16 

30.5 

22.6 

31.4 

24.5 

17 

30.8 

22.9 

31.8 

24.6 

18 

31.1 

23.4 

32.3 

25.5 

19 

31.5 

23.8 

32.6 

25.8 

20 

32.0 

24.1 

32.9 

25.8 

21 

32.3 

24.8 

33.3 

26.9 

22 

32.6 

25.3 

33.6 

27.0 

23 

32.9 

25.6 

33.8 

27.1 

24 

33.4 

26.4 

34.0 

27.9 

25 

33.8 

26.9 

34.1 

28.3 

26 

33.9 

27.3 

34.8 

29.0 

27 

33.9 

27.3 

35.1 

29.1 

28 

34.6 

27.8 

35.4 

29.3 

29 

34.8 

27.8 

35.4 

29.5 

30 

34.9 

28.3 

35.5 

30.5 

31 

35.1 

28.8 

36.0 

30.6 

32 

35.4 

29.0 

36.1 

30.6 

33 

35.6 

29.1 

36.5 

31.1 

34 

36.5 

30.1 

36.8 

31.9 

35 

36.5 

30.3 

37.1 

32.3 

36 

36.8 

30.5 

37.4 

32.3 

37 

36.8 

30.8 

37.5 

32.4 

38 

37.0 

31.0 

37.9 

33.1 

39 

37.3 

31.6 

38.5 

33.5 

40 

37.5 

32.0 

38.6 

33.6 

41 

37.8 

32.3 

38.6 

33.8 

42 

38.0 

32.5 

38.8 

33.8 

43 

38.3 

32.8 

38.9 

34.3 

44 

38.5 

33.0 

39.0 

34.5 

45 

38.5 

33.5 

39.0 

34.8 

46 

38.8 

33.5 

39.3 

35.8 

47 

38.9 

33.5 

39.5 

35.9 

48 

39.0 

33.8 

Crum,  F.  S.:    Quarterly  Publication  of  the  American  Statistical  Associ- 
ation, Boston,  September,  1916,  N.  S.,  No.  115,  xv,  332-336, 


114 


WEIGHT  PECULIARITIES 


Table  34. — Heights  and  Weights  of  Bovs  between  Five  to 
Fourteen  Years  (Withovt  Clothes). 


' 

■     1     1     1     !     j  bOYS 

" 

Weight  In  PoundB 

1 

Wi^thoul  Clothes 

"He 

igh 

In 

Fo 

ctand 

nches 

W 

tho'ut 

)ho<.» 

«G 

S-3 

SI 

J.5 

3.8 

3-7 

3-H 

S-9 

'•'S.I, 

4 

4-1 

..! 

4.3 

4.1 

4.5 

1.6 

4-9 

4-9 

'■'Vii 

3 

5-1 

5-2 

5-3 

5-4 

5-5 

S-O 

5-7 

5-S 

5-9 

^'Vii 

6 

6.1 

i 

» 

I^ 

39 

11 

12 

W 

6 

39 

39 

tl 

12 

U 

U 

43 

7 

)2 

13 

M 

IS 

ID 

Jl 

B 

<i 

13 

50 

53 

M 

57 

53 

U 

yj 

5S 

M 

\s 

(JO 

112 

la 

65 

III 

.« 

5.1 

is 

uo 

S2 

e:, 

BS 

C9 

71 

11 

61 

61 

69 

63 

71 

77 

77 

7S 

•S 

03 

67 

70 

75 

79 

79 

34 

34 

85 

13 

a7 

71 

75 

73 

M 

,S5 

96 

91 

93 

9^ 

100 

il 

n 

71 

70 

79 

"2 

b6 

80 

91 

07 

101 

107 

114 

122 

,5 

■ 

79 

J2 

S7 

91 

95 

99 

106 

112 

116 

119 

121 

!». 

133 

IS 

00 

96 

IM 

11! 

120 

122 

120 

rs 

133 

134 

l™ 

17 

m 

110 

117 

122 

125 

I2^ 

130 

136 

NO 

140 

m 

113 

121) 

120 

J26 

131 

133 

130 

113 

113 

l:> 

120 

12(1 

12» 

134 

13C 

>!i) 

144 

I4G 

140 

■M 

125 

13U 

132 

13? 

139 

115  116 

154 

1'15 

|— r- 

1 

1 

_ 

_ 

Metropolitan  Life  Insurance  Company. 


Table  35. — Heights  and  Weights  of  Girls  between  Five  to 
Fourteen  Years  (Without  Clothes). 


1      1 

1      1        GIRLS 

1  L  1 

~" 



Weigh 

t  h 

Pounds         i 

w 

tho'ut  tilothe 

He 

igh 

In 

Fe 

eta 

od  iiiches 

\v 

the 

ut 

Sho 

es 

AGE 

3-3 

3-4 

3-5 

3-6 

3-7 

3-8 

3-9 

3-1 

3-1 

4 

1-1 

1  2 

4-3 

4-J 

1-5 

1-0 

4-7 

4-6 

4-9 

4-lc 

4-1 

5.0 

5-1 

5-2 

3-3 

5-1 

5-5 

5 

34 

37 

35 

il 

11 

15 

6 

33 

37 

:9 

41 

43 

45 

43 

7 

.19 

42 

14 

45 

.7 

:ii 

" 

42 

45 

47 

« 

51 

53 

:e 

!) 

49 

31 

M 

:« 

59 

63 

lu 

54 

57 

3S 

.i2 

31 

33 

11 

3U 

fi2 

l!3 

83 

70 

7o 

12 

03 

'Uj 

lis 

■71 

75 

73 

33 

33 

91 

13 

8-i 

US 

73 

73 

80 

sa 

89 

91 

99 

101 

14 

75 

S3 

8S 

93 

!« 

m 

101 

107 

112 

114 

15 

69 

97 

100 

102 

J06 

l«l 

lis 

118 

16 

100 

101 

100 

111 

116 

116 

121 

17 

10(1 

100 

110 

11(1 

117 

125 

13 

iOI 

106 

107 

112 

111 

120 

10 

a-j 

105 

111 

113 

11!' 

123 

20 

XI 

111 

III 

III 

115 

125 

_ 

_ 

Mutual  Life  Insurance  Company, 


CHANGES  IN  WEIGHT  DURING  TREATMENT     115 


Table  3G.- 


-Heights  and  Weights  of  221,819  Men  op  Fifteen  or 
More  Years  of  Age  (With  Clothes). 


Graded  average  weight  in  pounds  with  clothes. 

Feet  and  inches  with  shoes. 

a 

< 

5-0 

5-1 

5-2 

5-3 

5-4 

5-5 

5-6 

5-7 

5-8 

5-9 

5-lC 

5-11  6-0 

6-1 

6-2  6-3 '6-4 

6-5 

13 

107 

109 

112 

115 

118 

122 

126 

130 

134 

138 

142 

147  152 

157 

162  167 1 172 1 177 

16 

109 

111 

114 

117  120 

124 

128 

132 

136 

140 

144  149  1.54 

159  164  169  174  179 

IV 

111 

113 

116 

119)  122 

126 

130 

134 

138 

142 

146  151  156 

161  166  171  176  i  181 

18 

113 

116 

118 

121 

124 

128 

132 

136 

140 

144 

148  153  j 158 

163  i  168 

173  :  178 

183 

19 

115 

117 

120 

123 

126 

130 

134 

138 

142 

146 

150  155  !  160 

165  170 

i 

175  180 

185 

20 

117 

119 

122 

125 

128 

132 

136 

140 

144 

148 

152  156  161 

166  171 

176  181  'l86 

21 

118 

120 

123  126! 130 

134  '  138 

141 

145 

149 

153  157  162 

167 ! 172 

177  182 

187 

22 

119 

121 

124 ! 127 ; 131 

135 

139 

142  1  146 

150 

1.54 

158  163 

168  173 

178  183 

188 

23 

120 

122  j 125 

128  1  132 

136 

140 

143 

147 

151 

155 

159  i  164 

169 ! 175 

180  i 185 

190 

24 

121 

123  126 

129  133 

137 

141 

144 

148 

152 

156 

160  1  165 

171  1  177 

182  i 187 

192 

25 

122 

124 

126 

129  133 

137 

141 

145 

149 

153 

157  162  i  167  173  !  179  !  184  189  194 

26 

123 

125 

127 

130  134 

138 

142 

146 

150 

154 

158  163  1  168  174  i  180  1  186  191  196 

2V 

124 

126 

128  131  134 

138 

142 

146 

150 ' 154 

158  1  163  :  169  175  181  187  192  197 

28 

125 

127 

129  132  135  1  139 

143 

147 

151  ;  1.55 

1.59  i  164  170 

176  182  188  193  198 

29 

126 

128 

130 

133 

136 

140 

144 

148 

152 

156 

160  165 

171 

177  183  189  ,  194  199 

30 

126 

128 

130 

133 

136 

140 

144 

148 

152 

156 

161  1  166 

172 

178  1  184  190  196  201 

31 

127 

129 

131 

134 

137 1 141 

145 

149 

153 

157 

162  ,  167  1  173 

179  185  i  191  197  202 

32 

127 

129 

131  134  !  137  1  141  i  145 

149 

1,54 

158 

163  1  168  174 

180  :  186  ,  192  198  203 

33 

12V 

129 

131  i  134  ;  137  ;  141  \  145 

149 

154 

159 

164  ,  169  :  175 

181  187  1193  199,204 

34 

128 

130 

132  135 

138 

142 

146 

150 

155 

160 

165 

170  176 

182 

188 

194  200  206 

35 

128 

130 

1 
132  135 

138 

142 

146 

150  1  155 

160 

165 

170  ■  176  ;  182 

189 

1 
195  201  207 

3b 

129 

131 

133  136  139  1  143 

147 

151  156 

161 

166 

171  177  183  ,  190  i  196  202  208 

3V 

129 

131 

133  i  136  ,  140  144 

148 

152  i  157 

162 

167 

172  1 178 1 184  191 1 197  203 ; 209 

38 

130 

132 

134  1  137  1  140  1  144 

148 

152  i  157 

162 

167 

173  !  179  ■•  185  192  1  198  104  1  210 

39 

130 

132 

134  I  137  :  140  ;  144 

148 

152  157 

162 

167 

173  179  185  192  :  199  205  i  211 

40 

131 

133 

135  \  138  141  145 

1 
149  153  1  158 

163 

168  \  174  ;  180  186  '  193  200  206  212 

41 

131 

133 

135  138  141  145  149  1  153  i  158 

163  168  174  180  '  186  193  \  200  207  213 

42 

132 

134 

136  139  142  146  150  154  159  164  169  175  181  187  194  201  208  214 

43 

132 

134 

136  139  142  146  150  154  159  '  164 

169  175  181  187  194  201  208  214 

44 

133  i  135 

137  140  1  143  ,  147  151  155  160  ,  165 

170  176  182  ,  188  ,  195  '  202  209  215 

45 

133  135 

137  140 

143  147 1  151  155  160  165 

170  176  1  182  188  ;  195  i  202  i  209  215 

46 

134  !  136 

138  141 

144  148  '•  152  156  161  166 

171  177  j  183  189  196  203  210  216 

47 

134  136  138  141 

144 

148  152  156  161 

166 

171  177 1  183  190  197  204  211  217 

48 

134 

136 

138 1 141 

144 

148  152  ,  156  ;  161 

166 

171  177  1  183  ,  190  ,  197  :  204  ,  211  217 

49 

134 

136 

138  141 

1 

144 

148 

152  156  161 

166 

171 

177  183  190  197  204  211  217 

50 

134 

136 

138  141 

144  '  148 

i   ! 

152  1  156  1  161 

166 

171 

i    1    : 
177  183  190  197:204  211  217 

51 

135 

137 

139  142  :  145  1  149  1 

153  !  157  1  162 

167 

172 

178  184  •  191  ■  198  <  205  212  218 

52 

135  137 

139  142  145  149  i  153  157  •  162 

167 

172  178  1  184  191  198  205  212  218 

53 

135 1 137 

139  142 

145  1  149  153  :  157  162 

167 

172  i  178 

184  ]  191  198  205  212  218 

54 

135  137 

139  I  142 

145  149  i  153  :  158  :  163 

168 

173  1  178 

184  ;  191  ,  198  205  212  219 

55 

135  137 

139  142 

145  !  149  ,  153  158  163 

168 

173  178 

1 

184  191 !  198  1  205  212  219 

1 

Association  of  Life  Insurance  Directors  and  Actuarial  Society  of  America, 
New  York,  1912,  pp.  38  and  67.  Published  by  a  committee.  Allow  one 
inch  for  shoes  and  ten  pounds  for  clothes. 


116 


WEIGHT  PECULIARITIES 


Table  37. — Heights  and  Weights  of  136,504  Women  of  Fifteen 
OR  More  Years  of  Age  (With  Clothes). 


Graded  average  weight  in  pounds  with  clothes. 

Feet  and  inches  with  shoes. 

< 

4-8  ^  4-9  4-104-11  5-0  5-1 

5-2 

5-3  I  5-4 

1 

5-5 

5-6 

5-7 15-8 

5-9  5-lC 

5-11 

6-0 

15 

101 '  103  '  105  '  106  '  107  109 

112 

115 'lis 

122 

126 

130 !  134 

138  142 

147 

152 

IB 

102  104  100  108  109  j  111 

114 

117  1201124 

128  1  132  136 

139  143 

148  153 

IV 

103  105  107  109  111  113 

116 

119  122  125 

129  133  137 

140 • 144 

149  154 

18 

104  106  108  110  112  114 

117. 

120  123  126 

130  j  134  '  138 

141  145 

150  !  155 

19 

105  107  109  111  113  115 

118 

121 1 124  127 

131  135  139 

1 

142  146 

151  155 

20 

i    ! 
106  lOS  110  1121114  116 

119 

122  125 1  128  132  136  140  143  147 

151  156 

2i 

107  109  111  113  115!  117 

120 

123 ' 126 1 129 

133  1  137  1  141  144  1148 

152  156 

22 

107  1109  ml  1131  115!  117 

120 

123  126  !  129 

133 : 137  141  I  145 1 149 

153  157 

23 

108  110  112  114  116'  118 

121 

124  .127  130 

134  138  142  146 ' 150 

153  157 

24 

109 

HI  113  1115 

1    1 

117  119  121 

124 

127 1 130 

134  138  142  1  146  150 

154 1 158 

25 

109 

111  113  115 

117  119 

121 

124 

128  131 

135 

139  143 

147 

151 

154  158 

26  110 

112  114  116 

1181120 

122  125! 128  I  131 1135 

139  143  1  147  1  151 

155  159 

27 

110;il2  114,  116  118  120  122  125  129  132  136  140  144  i  148  152 

155 ' 159 

28 

111 ! 113  115  i 117 ! 119  i 121 1 123  126 1 130  133 1 137 

141  145 

149 

1.53 

156 , 160 

29 

111 

113  115 

117 

119  121 

123  126 

130 

133 

137 

141 

145 

149 

153 

156  1  160 

30 

112 

114  116 

118 

120  122 

124  127 

LSI 

1.S4 

1.38 

^4?. 

146 

150 

1.54 

157  161 

31  113  115  117  119 

121  123 

125  128  132  ,  135  139  ;  143  147 

151 1 154 

157 1 161 

32  113  115 

117  119 

121  1  123 

125  1  128  ,  132  1  136  '  140  1  144  1  148  j  152  1  155 

158  i 162 

33  114  116 

118  120 

122  124 

126  i  129  1  133  1  137  ,  141  145  149  i  153  1  156 

159  162 

34 
35 

115  1117 

119  121 

123  !  125 

127  ;  130  1 134  !  138  1 142  146  150 

!       1    1    1 

154  157 

160  163 

115  117 

119 '121 

123  '  125 

127  130  1  134  138  142  1  146  150 

154  157 

160  163 

36  116  lis 

120 1 122 

124  1  126 

128  131  ,  135  ;  139  143  ,  147  1  151 

155  158 

161  164 

37  1  116 ,118 

120  122  124 ' 126 

129  132  136  140  144  148  152  ]  156  159 

162  1'65 

38 1 117  119 

121 1 123  125  127 

130  133  137  141  145  '  149  1,53  !  157  1  160 

163  1  166 

39 

118  i 120 

122 , 124 

1 

126  128 

131 

134  ,  138  ,  142  1  146 

150 , 154 

158 

161 

164  167 

40 

119  121 

123 

125 

127  129 

132 

135  138 

142  146 

1.50 

1,54 

158 

161 

164  167 

41  120  122 

124  '  126  :  128  130 

133  136  139  ,  143  147  151  155 

1.59  162 

165  168 

42  120  122  124  126  128  130  ^  133  ;  136  139  143  147  151  155  !  159  1  162 

166  1  169 

43 , 121  123 

125  127  129  :  131  134  137  140  144  148  ,  152  156 

160  163 

167  170 

44 

122  124 

I 

126  128  [130  132  135  138  141  145  149  153  157 

161 

164 

168  171 

45 

122  124 

126  128  130  132  135  138  141  145  149  '  1.53  157 

161 

164 

168 : 171 

4b 

123  125 

127  1129  1311133  136  139  142  146  1  1.50  154  158 1  162  165  1169:172 

47  123  125 

127 

129  131  133  136  139  142  146  151  ,  155  159 

163  166  170  173 

48  124  126 

128 

130  132  134 !  137  140  143 

147  152  156  1  160 

164  1  167 

171  174 

49  124  126 

128 

130  132  134  i  137  140  143 

147 : 152  156  j 161 

1    1 

165  168 

172  i  175 

50  125  1  127 

129 

131  133  135  138  141  144 

148  152  156  161 

165  169 

173  176 

51  125  127 

129 

131 ;  133  135  138  141  144 

148  152  157  162 

166 1 170 

174  177 

52  '  125  !  127 

129 

131  1  133  1  135  138  141  144 

148  1  1.52  !  157  '  162 

166  170 

174 1 177 

53  125  127 

129 

131  133  135 1  138  141  144 

148  1.52  1  157  162 

166  ,  170 

174 1 177 

54  ^ 

55' 

125  127 

129 

131  133  135  138 ;  141  144 

148 

153 

158  163 

167  171 

174 

177 

125 

127 

129 

131 

133  135 ' 138 ! 141 ' 144 

148 

153 

158  163 

167  171 

174 

177 

Association  Life  Insurance  Directors  and  Actuarial  Society  of  America, 
New  York,  1912,  pp.  38  and  67.  Published  by  a  committee.  Allow  one 
and  a  half  inches  for  shoes  and  six  pounds  for  clothes. 


CHANGES  IN  WEIGHT  DURING  TREATMENT     117 

It  is  also  interesting  that  although  the  carbohydrate  in 
an  individual's  diet  is  replaced  by  an  equivalent  number  of 
calories  in  the  form  of  fat,  the  weight  promptly  falls,  and  if 
the  reverse  procedure  is  adopted  the  weight  will  rise.  The 
loss  or  gain  of  weight  which  occurs  under  such  conditions 
may  amount  to  two  pounds  in  a  day  for  several  days.  Finally, 
there  is  a  real  reason  for  a  loss  of  weight  during  the  treat- 
ment of  diabetes,  due  to  the  fact  that  the  diet  is  often  defi- 
cient in  calories.    Against  this  loss  we  must  fight! 

The  foregoing  height  and  weight  tables  (Tables  33  to  37 
inclusive)  were  selected  by  Dr.  Horace  Gray  as  the  most 
satisfactory  in  the  literature. 


CHAPTER  XII. 
THE  DIABETIC  DIET  IS  EXPENSIVE. 

This  is  true  whetlier  the  patient  is  untreated  or  treated, 
but  in  the  former  state  tlie  waste  of  food  is  enormous. 

Case  No.  1171,  before  treatment  was  begun,  told  me  that 
he  ate  thirteen  eggs  for  breakfast,  not  by  any  means  as  a 
stunt,  but  because  he  wanted  them.  Case  No.  1147,  a  hidy 
of  thirty-five  years  of  age,  ate  a  dozen  eggs  a  day,  and  in 
response  to  my  request  gave  me  a  report  of  her  daily  diet 
before  she  began  treatment.  This  is  shown  in  Table  37.  It 
will  be  observed,  however,  that  the  carbohydrate  was  below 
normal — good  e^■idence,  therefore,  that  her  diet  had  already 
been  somewhat  altered  from  the  normal  before  the  time 
at  which  she  reported;  in  fact,  I  thmk  her  diet  was  origi- 
nally considerably  in  excess  of  that  recorded. 

Table  38. — ^Estimated  Diet  of  a  Woman  of  Thirty-five  Years, 
Case  No.  1147,  Prior  to  Treatment.     Weight,  Seventy- 
two  Kilograms. 

Food  for  twenty-four  Carbohydrate,  Protein,  Fat, 

hours.  Quantity.  grams.  grams.  grams. 

Eggs 12  0  72  72 

Five  per  cent,  vegetables  450  grains.  15  8  0 

Milk 2000  c.c.  96  64  64 

Forty  per  cent,  cream        .  240  c.c.  8  8  96 

Butter 90  grams.  0  0  75 

Meat 120  grams.  0  32  20 

Bread 100  grams.  60  10  0 

Totals      .179  194  327 

4  4  9 

Total  calories  716  776  2943 

Total  calories  4435  -H  72  kilograms  =  approximately  60  calories  per 
kilogram  body  weight. 

Although  the  diet  contained  60  calories  per  kilogram  body 
weight  instead  of  the  normal  30  calories,  the  patient,  while 
(118) 


DJABETIC  DIET  IS  EXPENSIVE  110 

upon  it,  lost  '66  pounds  in  a  little  over  two  and  a  half  years. 
The  reason  for  this  was  apparent,  for  on  October  G,  1916, 
the  volume  of  the  urine  was  estimated  at  6000  c.c.  (6  quarts) 
and  the  sugar  was  found  to  be  5  per  cent.,  or  300  grams 
(10  ounces),  the  equivalent  of  a  loss  of  1200  calories  in  the 
urine  in  twenty-four  hours.  In  one  year  this  would  amount 
to  240  pounds  of  sugar!  After  a  two  weeks'  stay  in  the  hos- 
pital she  felt  more  content  with  a  diet  of  1600  calories — a 
trifle  less  than  her  body  needs — than  when  upon  the  4400 
calories  at  entrance. 

It  is  obvious  that  the  saving  of  food  which  results  from 
becoming  sugar-free  under  modern  treatment  must  be  con- 
siderable. It  is  the  diet  of  the  untreated  diabetic  which  is 
expensive,  since  the  large  excess  is  far  worse  than  wasted. 

Case  No.  295  voided  in  twenty-four  hours,  on  October 
23-24,  1909,  approximately  10  liters  of  urine  (nearly  20 
pounds),  containing  680  grams  of  sugar,  the  equivalent  of 
2720  calories!  The  weight  of  this  patient  was  50  kilos.  In 
other  words,  he  lost  in  the  urine  54  calories  per  kilo,  an 
amount  sufficient  in  calories  to  supply  almost  double  his 
own  needs  if  taken  in  the  form  of  food  which  he  could 
assimilate.  He  must  have  eaten  as  much  as  three  men  of 
his  own  size. 

Diabetic  patients  with  acid  poisoning  lose  calories  in  the 
urine  not  only  in  the  form  of  sugar  but  as  acid  bodies  as  well. 
The  quantity  of  acid  bodies  thus  lost  is  quite  considerable. 
These  acid  bodies  represent  wasted  food  just  as  much  as 
does  the  sugar  in  the  urine.  Case  No.  344  is  a  good  illustra- 
tion of  this.  On  December  25-26,  1911,  he  excreted  188 
grams  sugar,  the  equivalent  of  (188  X  4)  752  calories,  and 
in  addition  55  grams  acid  bodies,  equivalent  to  (55  X  5) 
275  calories.  Acid  intoxication  is  really  a  dreadful  robber, 
for  besides  stealing  the  food  of  a  patient,  it  frequently  steals 
his  life! 

The  diet  of  the  treated  diabetic  is  also  expensive.  In 
comparing  the  diet  of  the  diabetic  patients  with  those  of 
the  non-diabetic  patients  at  the  New  England  Deaconess 
Hospital,  Miss  Dike  and  Miss  Wallace  found  that  the  dia- 
betic diet  was  26  per  cent,  more  expensive.     The  diabetic 


120 


DIABETIC  DIET  I     EXPENSIVE 


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DIABETIC  D.\^T  IS  EXPENSIVE  121 

patient  cannot  subsist  on  cheap  carboliydrate  foods  siicli 
as  cereals,  bread  and  potatoes,  but  must  replace  these  with 
expensive  varieties  such  as  eggs,  meat,  broths  and  fresh 
vegetables.  In  addition  to  the  cost  of  the  raw  materials 
the  labor  entailed  in  the  preparation  is  a  factor  of  consider- 
able importance. 

The  diabetic  who  must  save  expense  could  attain  his  object 
if  he  used  tea  and  cocoa  shells  instead  of  coffee  and  cracked 
cocoa,  gelatin  and  agar-agar  sparingly  or  not  at  all,  substi- 
tutes for  butter  instead  of  bacon  and  cream,  the  cheaper  kinds 
of  vegetables,  whether  fresh  or  canned,  and  of  meat  and  fish, 
and  finally  omit  broth.  The  home  canning  of  vegetables  in 
diabetic  families  should  be  encouraged.  A  garden  is  a  great 
advantage. 


CHAPTER   XIII. 
CARE  OF  THE  TEETH. 

Many  diabetics  have  sound  teeth,  thus  showing  that 
diabetes  is  not  necessarily  productive  of  bad  teeth.  On  the 
other  hand  the  teeth  should  always  be  kept  in  good  condi- 
tion, for  it  is  common  to  have  the  diabetes  grow  worse  in  the 
presence  of  inflammatory  conditions  about  the  teeth,  and 
gmns.  The  teeth  should  be  cleaned  after  each  meal  and  it 
is  desirable  to  have  them  cleaned  by  a  dentist  at  least  every 
three  months.  If  the  teeth  are  to  be  extracted,  novocain 
injected  cautiously  acts  admirably.  If  necessary,  gas  or 
gas  and  oxygen  may  be  employed,  but  ether  and  chloroform 
are  to  be  avoided  for  fear  of  bringing  on  acid  poisoning. 

The  care  of  the  teeth  is  of  enough  importance  to  warrant 
the  insertion  of  the  following  abstract  of  a  dentist's  leaflet, 
which  supplies  specific  instruction  on  this  subject. 

Clean  Teeth  Will  Not  Decay. 

How  can  all  the  food  be  removed  from  all  the  surfaces  of 
all  the  teeth  after  each  meal? 

1.  By  brushing. 

2.  By  using  floss  silk  between  the  teeth. 

3.  By  thoroughly  rinsing  the  mouth  with  lime  water. 
Rules  for  Brushing  the  Teeth. — 1.  Brush  four  times  a  day: 

Before  breakfast,  with  clear  water. 

After  each  meal,  with  a  tooth  paste  or  powder. 

The  teeth  must  be  clean  and  free  from  food  before 

going  to  bed,  as  most  of  the  decay  takes  place  while 

sleeping. 
2.  Brush  two  minutes  each  time.    If,  however,  the  teeth 

are  kept  well  polished   by  the  dentist  a  lessened 

brushing  time  will  suffice.    This  depends  upon  the 

individual  case. 

( 122 ) 


CARE  OF  THE  TEETH  123 

It  takes  two  minutes  of  brushing  to  properly  stimulate 
the  gums  and  thoroughly  cleanse  the  teeth.  Be  sure 
and  brush  the  gums. 

3.  Do  not  use  pressure  with  the  brush.     A  fast,   light 

stroke  is  the  best.     A  brush  should  never  be  worn 
out  by  having  its  bristles  flattened  and  spread  out. 

4.  Candies,  sugar,  crackers,  cake,  pastries,  bread  will  make 

the  teeth  decay  if  allowed  to  remain  on  their  surfaces. 

Floss  Silk. — Four-fifths  of  the  decay  of  teeth  takes  place 
on  the  surfaces  between  the  teeth  and  one-fifth  on  the  sur- 
faces on  which  one  chews.  There  is  but  one  way  which  is 
effective  in  removing  the  food  from  between  the  teeth,  and 
that  is  with  a  piece  of  floss  silk. 

Use  a  section  of  floss  about  twelve  inches  long.  Hold 
one  end  between  the  thumb  and  first  finger  of  the  left  hand 
and  wrap  the  floss  twice  around  the  end  of  the  first  finger. 
Do  the  same  with  the  thmnb  and  first  finger  of  the  right 
hand.  Now  by  using  combinations  of  the  ends  of  the  thiunbs 
and  second  fingers  the  flo^s  may  be  carried  into  the  mouth 
and  forced  carefully  between  all  the  teeth.  Rub  it  back  and 
forth  against  the  surfaces  of  each  tooth  to  loosen  and  remove 
the  food  and  to  clean  these  surfaces.  After  a  little  practice 
one  can  floss  all  the  surfaces  between  the  teeth  in  a  minute's 
time. 

There  still  remains  on  the  surfaces  of  the  teeth,  especially 
between  them,  a  glue-like  deposit  known  as  mucin.  This 
mucin  must  be  removed,  as  it  allows  the  bacteria  to  cling  to 
these  surfaces.  The  most  effective  and  harmless  solvent 
to  use  as  a  mouth  wash  is  lime  water.  In  fact  if  but  one 
thing  could  be  used  to  prevent  decay  of  the  teeth,  lime  water 
used  three  times  daily  would  prove  to  be  the  most  valuable. 

Pre'paraiion  of  Lime  Water. — SecLire  coarse,  mislaked  lime 
and  crush  it  into  a  fine  pow^der.  Place  a  half-cupful  m  an 
empty  quart  bottle  and  fill  nearly  full  with  cold  water. 
Thoroughly  shake  and  then  allow^  the  lime  to  settle  to  the 
bottom  of  the  bottle,  which  will  take  several  hom-s.  Avoid 
injmy  to  furnitm-e  from  heat  generated  in  the  bottle.  After 
the  lime  has  settled  pour  oft'  as  much  of  the  clear  water  as 
possible  without  losing  any  of  the  lime,  as  this  first  mixing 


124  CAEE  OF   THE   TEETH 

contains  the  washing  of  the  ILine.  Again  fill  A\itli  cold  water, 
shake  well  and  allow  it  again  to  settle. 

Into  an  empty  twelve-onnce  bottle  pour  the  clear  lime 
water,  taking  care  not  to  stir  up  the  lime  in  the  bottom  of  the 
bottle.  Again  fill  the  quart  bottle  with  cold  water,  shake 
thoroughly  and  set  it  aside  to  use  when  the  smaller  bottle 
becomes  empty.  This  process  may  be  repeated  until  the 
half-cup  of  lune  has  made  five  or  six  quarts  of  mouth  wash. 

The  tweh-e-ounce  bottle  is  used,  as  it  is  more  easily  handled 
at  the  wash  bowl.  After  brushing  and  flossing  the  teeth, 
pour  out  a  little  of  the  lime  water  in  a  glass  and  taking  it  in 
the  mouth  force  it  back  and  forth  between  the  teeth  with 
the  tongue  and  cheeks  until  it  foams.  If  you  rinse  it  long 
enough  to  make  it  foam  it  has  then  been  in  the  mouth 
long  enough  to  have  a  beneficial  action  on  the  teeth.  After 
spitting  it  out  rinse  the  mouth  with  clear  water  to  take  away 
the  taste  of  the  lime.  If  the  lime  water  is  a  little  strong  at 
first,  dilute  it  with  clear  water  in  the  small  bottle,  half  and 
half.  It  should  be  used' clear  and  full  strength  as  soon  as  the 
giuns  become  hard  and  healthy  from  brushing. 


CHAPTER  XIV. 
CARE  OF  THE  SKIN. 

The  skin  must  be  kept  unusually  clean.  Take  a  tub 
bath  daily,  but  avoid  prolonged  cold  baths.  Short  cold 
baths  are  often  desirable.  A  certain  boy  took  his  cold  morn- 
ing bath  in  four  seconds;  adults  often  go  to  the  other  extreme 
in  point  of  time  and  thus  lose  the  good  effect. 

Protect  the  Skin  from  Injuries.^ — If  any  infection  occurs  see 
a  physician  at  once.  Infections  of  the  skin  are  apparently 
less  common  now  than  formerly,  and  this  may  be  attributed 
to  cleanliness.  Such  infections  are  and  should  be  rare  in 
diabetic  patients  under  treatment.  They  demand  imme- 
diate, thorough,  yet  gentle  treatment.  One  of  the  first 
duties  of  a  physician  is  to  tell  diabetic  patients  to  keep  the 
skin  clean  and  to  report  the  beginning  of  an  infection  at 
once.  Patients  should  be  warned  of  the  danger  from  slight 
wounds,  should  be  specifically  advised  not  to  allow  mani- 
curists or  chiropodists  to  draw  a  drop  of  blood  and  cautioned 
to  promptly  report  any  injury  to  the  skin.  A  neglected 
sore  on  a  toe  has  cost  many  a  diabetic  his  leg  and  not  a  few 
their  lives.  If  such  a  condition  is  reported  to  the  physician 
and  the  patient  stays  in  bed  from  the  start,  healing  can 
readily  take  place. 

Absolute  cleanliness  of  the  body  is  essential.  Subcuta- 
neous injections,  whether  of  water,  salt  solution  or  drugs, 
may  be  harmful,  but  with  modern  asepsis  perhaps  can  be 
safely  employed.  It  is  common  for  salt  solution  or  solu- 
tions of  sodium  bicarbonate,  when  injected  subpectorally, 
to  result  in  abscess.  If  there  is  the  slightest  tendency  to 
furunculosis  my  custom  is  at  once  to  adopt  simple  measures 
analogous  to  those  described  by  Bowen.^    The  patient  is 

iBowen:  Jour.  Am.  Med.  Assn.,  1910,  Iv,  209;  Boston  Med.  and  Surg. 
Jour.,  1917,  clxxvi,  96. 

(125) 


126  CARE  OF  THE  SKIN 

advised  to  wash  the  whole  body  twice  a  day  with  soap  and 
water,  using  a  wash-cloth  or  piece  of  flannel,  and  to  dry  the 
skin  without  rubbing,  so  as  to  avoid  breaking  open  any 
pustule;  the  whole  body  is  then  bathed  with  a  saturated 
solution  of  boracic  acid  in  water,  with  the  addition  of  a 
small  proportion  of  camphor  water  and  glycerin.  A  solu- 
tion of  2  parts  alcohol  and  1  part  water  has  often  worked 
to  advantage,  but  Bowen  in  his  second  paper  still  prefers 
the  boracic  acid.  Individual  furuncles  may  be  treated  with 
the  following  ointment,  according  to  Bowen: 

Boracic  acid 4 

Precipitated  sulphur 4 

Carbolated  petrolatum 30 

One  shoidd  be  careful,  however,  not  to  overtreat  the  skin. 
Harm  may  result  from  frequent  dressings.  The  simplest 
lotions  should  always  be  employed.  In  se\ere  cases  the 
patient  should  be  put  to  bed,  all  linen  changed  twice  daily, 
and  the  patient  treated  in  as  aseptic  a  way  as  possible.  In 
a  few  cases  vaccines  have  appeared  to  be  of  marked  benefit. 
"This  procedure,  thorough  bathing  and  soaping,  the  applica- 
tion of  the  borated  solution,  and  the  dressing  of  the  individual 
fm-uncles,  is  repeated,  as  has  been  said,  morning  and  night. 
A  further  point  of  vital  importance  relates  to  the  clothing 
that  is  worn  next  the  skin.  Every  stitch  of  linen  worn  next 
to  the  skin  should  be  changed  daily,  and  in  the  case  of 
extensive  fm'unculosis  all  the  bedclothing  that  touches  the 
individual,  as  well  as  the  nightclothing,  should  be  subjected 
to  a  daily  change.  Natm-ally,  this  treatment  must  be  con- 
tiiiued  for  several  iceeks  after  the  last  evidence  of  injogenic 
infection  has  apjjeared,  and  this  fact  must  be  emphasized 
to  the  patient  at  the  outset."     (Bowen.) 


CHAPTER  XV. 

TREATMENT  OF  CONSTIPATION  AND 
DIARRHEA. 

The  bowels  should  move  daily.  To  this  end  nothing 
compares  in  effectiveness  with  the  cultivation  of  regular 
habits  and  hours  for  this  purpose.  Time  is  required  and 
half  an  hour  or  even  more  at  the  same  time  of  the  day 
for  three  successive  days  will  often  bring  relief  from  consti- 
pation and  this  will  persist  for  months.  The  coarse  vegetables 
and  fruit  of  the  diet  may  prove  quite  sufficient,  but  if  neces- 
sary bran  muffins  made  with  agar-agar  (see  page  137)  may 
be  employed.  If  potatoes  are  included  in  the  diet  the  baked 
potato  skins  may  solve  the  difficulty.  Never  purge  the 
bowels,  but  depend  upon  an  enema  or  upon  simple  laxatives, 
such  as  aloin,  grain  |;  fluid  extract  of  cascara  sagrada  10 
to  30  drops;  extract  cascara  sagrada  5  grains  or  compound 
rhubarb  pills. 

If  the  patient  has  not  had  a  movement  for  several  days, 
at  the  beginning  of  treatment  give  an  enema  followed  by 
some  simple  cathartic  or  mild  aperient,  and  another  enema 
twelve  to  twenty-four  hours  later;  but  do  not  purge  the 
patient.  Gain  enough  is  obtained  if  a  movement  is  produced 
once  in  twenty-foiu"  hours  when  it  has  only  been  taking  place 
once  in  seventj'-two.  In  other  words,  do  not  upset  any 
patient  who  is  in  a  tolerable  state. 

The  following  exercises  for  constipation  were  recommended 
to  me  by  Mr.  Gustaf  Sundelius : 

Home  Exercises  for  Constipation. 

1.  Abdominal  Kneading  and  Stroking. —  Kneading. — Lying 
dow^n,  with  knees  slightly  drawn  up.  Place  hands  one  on 
top  of  the  other  on  the  abdomen  at  the  right  groin;  with 

(127) 


12S     TREATMENT  OF  CONSTIPATION  AND  DIARRHEA 

small  circular  movements  and  deep  pressure  work  upward 
until  the  ribs  are  met,  then  across  toAvard  left,  following  the 
boundary  line  of  the  chest,  then  downward  to  the  left  groin. 
Repeat  twenty  to  fifty  tunes.  Stroking.  With  hands  simi- 
larly placed,  make  long,  steady  and  deep  strokes,  following 
the  same  route.    Repeat  twenty-fi\'e  to  one  hundred  times. 

2.  Leg-rolling. — Lying  down,  take  hold  of  both  legs  just 
below  the  knees,  press  the  knees  up  close  to  the  abdomen, 
then  carr}^  them  apart,  then  down  and  inward  until  they 
meet  again,  thus  letting  the  knees  describe  two  circles. 
Repeat  ten  to  twenty  times. 

o.  Ahdoininal  Compression. — Standing  against  the  wall 
with  hands  clasped  behind  neck,  draw  the  abdomen  forcibly 
in,  using  the  abdominal  muscles,  hold  a  second,  then  let  go. 
Repeat  ten  to  forty  times. 

4.  Trunk-rolling. — Standing  with  hands  on  hips,  feet 
apart  and  legs  well  stretched,  roll  the  upper  body  in  a  circle 
on  the  hips  by  bending  forward,  to  the  left,  backward,  and 
to  the  right.  Then  reverse,  and  repeat  six  to  twelve  times 
each  way. 

Case  No.  559  warded  off  constipation  by  sawing  wood, 
and  Case  No.  265  regulated  his  bowels  by  eating  a  slice  of 
raw  cabbage  for  breakfast. 

The  reverse  of  constipation,  diarrhea,  is  rare  in  diabetes. 
When  it  occurs  the  patient  should  immediately  go  to  bed, 
keep  warm  and  live  upon  hot  water,  and  in  exceptional  cases 
upon  boiled,  skimmed  milk.  The  bowels  should  be  cleared 
with  an  enema,  and  if  there  is  any  suggestion  of  undigested 
food  remaining  in  the  stomach  this  should  be  removed  by 
lavage  or  induction  of  vomiting.  The  physician  may 
administer  an  opiate.  Rest  in  bed  is  the  essential  and  the 
best  sort  of  treatment.  The  diet  should  be  gradually 
resumed,  adding  the  coarse  vegetables  last.  The  few  days 
of  restricted  quantities  of  food  may  be  of  real  help  to  the 
patient. 


CHAPTER  XVI. 
DRUGS  IN  THE  TREATMENT  OF  DIABETES. 

Deugs  are  not  recommended  by  physicians  like  Professor 
Naunyn,  the  Nestor  of  diabetic  treatment,  or  by  those  con- 
cerned in  the  recent  advance  in  diabetic  treatment  in  this 
country. 

Drugs  are  not  prescribed  with  the  purpose  of  lowering 
the  sugar  in  the  urine  in  the  most  famous  of  our  large 
hospitals.  Drugs,  however,  are  often  useful  to  relieve 
special  symptoms.  Theocin  and  diuretin  will  often  remove 
an  obstinate  edema  within  two  days. 

On  the  other  hand,  drugs  are  frequently  recommended  by 
those  who  have  proprietary  preparations  to  sell. 


(129) 


CHAPTER  XVII. 
DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS. 

The  narrow  confines  of  the  diabetic  diet  have  greatly 
stimulated  the  manufactiu-e  of  so-called  diabetic  foods. 
These  are  often  serviceable,  but  are  to  be  employed  with 
discretion.  Their  use  should  be  discoiuaged  at  the  beginning 
of  treatment.  The  patient  should  never  become  dependent 
upon  special  diabetic  foods,  for  they  are  often  unobtainable, 
always  make  him  conspicuous,  and  when  he  acquires  a 
disgust  for  foods  of  this  class  it  is  all  the  harder  to  abide  by 
the  original  diet.  When  the  patient  buys  one  of  these  foods, 
unfortunately  he  is  often  given  a  list  of  other  diabetic  foods 
and  a  new  diabetic  diet  list,  and  confusion  in  the  diet  may 
residt.  The  patients  under  my  care  who  have  done  best 
either  never  use  special  diabetic  foods  or  only  a  few  varieties. 

Substitutes  for  Bread.— Many  of  the  preparations  upon  the 
market  contain  as  great  or  even  a  greater  quantity  of  car- 
bohydrate than  ordinary  bread;  a  few  contain  less;  but  the 
percentage  of  carbohydrate  may  vary  from  time  to  time. 
Patients,  and  sometimes  physicians,  forget  that  substitutes 
for  bread  must  be  prescribed  only  in  definite  amounts.  A 
diabetic  bread  should  never  be  prescribed  without  a  knowl- 
edge of  its  content  of  carbohydrate,  protein  and  fat. 

The  bread  of  one  of  the  largest  bakeries  in  Boston,  upon 
analysis,  showed  55  per  cent,  carbohydrate.  Bread  made 
without  milk  or  sugar,  but  with  water  and  butter,  con- 
tains 45  to  50  per  cent,  carbohydrate.  Such  a  bread  is 
undoubtedly  superior  to  many  different  bread  substitutes 
upon  the  market.  The  percentage  of  carbohydrate  in  toast 
is  greater  than  in  plain  bread,  because  it  contains  less  water. 
Some  of  the  coarser  kinds  of  bread,  such  as  rye  bread,  graham 
bread,  black  bread  and  pumpernickel,  contain  somewhat  less 
(130) 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     131 

carbohydrate.    Never  give  bread  substitutes  early  in  treat- 
ment.   Teach  patients  to  Kve  without  them. 

Bran  Bread. — Bran  is  being  more  and  more  employed  in 
the  diet  of  diabetic  patients.  This  is  neither  more  nor  less 
than  the  use  of  cellulose,  and  this  is  supposed  to  have  no 
effect  upon  the  metabolism.  Unfortunately,  the  availability 
of  the  protein,  fat  and  carbohydrate  of  wheat  bran  to  the 
diabetic  patient  has  not  been  determined,  although  there  are 
plenty  of  data  upon  its  digestibility  by  ruminant  animals. 
Bread  made  of  bran  alone  is  not  very  palatable,  though  with 
the  fat  of  bacon  or  butter  it  is  liked  better.  It  furnishes 
bulk  and  acts  favorably  upon  constipation.  If  made  with 
eggs  and  butter  the  flavor  is  improved.  It  should  be 
remembered  that  bran  often  contains  a  considerable  quantity 
of  starch.  For  this  reason  bran  biscuits  often  prove  to  be  a  de- 
lusion and  a  snare,  and  one  dreads  to  see  them  on  a  patient's 
tray.  In  large  hospitals  where  diabetic  patients  are  con- 
stantly being  treated  the  danger  is  less,  for  the  bran  is  bought 
by  the  same  person  and  at  the  same  place;  but  in  private 
practice  this  is  different.  In  purchasmg  bran  go  to  a  feed 
store  and  ask  for  coarse  bran  for  cattle  and  not  for  bran  for  the 
table.  The  various  preparations  of  bran,  bran  breads  and 
cookies  sold  under  trade  names  often  contain  carbohydrate 
other  than  bran,  hence  the  reason  for  their  agreeable  taste; 
beware  of  them!  They  may  contain  over  60  per  cent, 
carbohydrate,  of  which  less  than  10  per  cent  is  real  bran. 
Mild  diabetics  get  into  little  trouble  with  bran,  but  the 
serious  ones  often  suffer.  The  starch  may  be  washed  out 
with  water  by  tying  the  bran  in  a  cheesecloth,  soaking  one 
hour  in  running  water  by  fastening  the  same  on  a  faucet.  It 
should  be  thoroughly  mixed  and  kneaded  from  time  to  time 
to  be  sure  the  water  reaches  all  portions,  and  should  be 
washed  until  the  water  comes  away  clear.  This  may  require 
an  hour.^ 


^  Four  preliminary  analyses  of  washed  bran  showed  the  following  per- 
centages of  starch:  0.6,  1.8,  2.7,  5.2  per  cent.  Two  preliminary  analyses 
showed  pentosan  29.8,  33.5.  The  wide  variations  in  the  percentages  of 
starch  will  account  for  the  occasional  occurrence  of  sugar  in  the  urine  fol- 
lowing the  use  of  bran  cakes. 


132    DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS 

Gluten  Breads. — ^l"'hese  broads  are  made  by  reinoxinjr  tlie 
sugar-forining  material  from  the  flour.  It  is  surprising  how 
thoroughly  this  can  be  done.  The  large  quantity  of  protein 
in  small  bulk  which  they  contain  is  objectionable. 

Light  Breads. — French  bread  cut  in  thin  slices  is  often 
useful,  because  it  is  bulky  and  gives  the  a])])carance  of  a 
large  quantity.  ]\lanufactiu"ers  have  taken  ad\antage  of  this 
idea  and  many  light  breads  are  on  the  market.  These  breads 
often  contain  about  the  same  quantity  of  carbohydrate  as 
ordinary  bread,  though  a  few  contain  considerably  less. 
Their  virtue  often  consists  solely  in  their  bidk,  which  allows 
a  surface  on  which  to  spread  butter.  I  seldom  a(hise  breads. 
It  is  better  for  the  patient  to  forget  the  taste. 

Various  other  substances  have  been  used  for  flour  in  the 
manufacture  of  bread.  Thus,  aleiu-onat  meal  has  been 
employed,  and  with  it  have  been  mixed  various  vegetable 
products.  A  gi'oup  of  casein  breads  is  upon  the  market  in 
the  form  of  casoid  flour  under  various  names,  and  to  some 
diabetics  these  are  \'aluable. 

Soy  bean  is  also  extensively  used  and  probably  deserves  a 
still  wider  introduction  into  the  diabetic  diet.  The  carbo- 
hydrate in  it  is  unassimilable.  It  is  also  used  in  the  manu- 
facture of  flour.  Agar-agar  may  be  used  to  dilute  the  flour 
or  to  add  to  bran  and  also  to  relieve  the  constipation  of  the 
diabetic,  which  is  frequently  troublesome. 

Substitutes  for  Milk. — ^A  few  tablespoonfuls  of  cream  are  a 
great  comfort  to  a  diabetic  patient.  Except  in  cases  with  a 
very  low  tolerance  a  gill  (120  c.c.)  of  20  per  cent,  cream  can 
generally  be  allowed,  and  if  it  is  desirable  to  give  more  fat 
without  increasing  carbohydrate  and  protein  a  gill  of  40 
per  cent,  cream  is  also  well  borne.  Formerly  patients  took 
half  a  pint  of  40  per  cent,  cream  readily.  With  severe  cases 
it  is  seldom  possible  to  allow  more  than  60  to  90  c.c.  of  20 
per  cent,  cream,  for  the  balance  of  the  fat  which  can  be 
safely  employed  can  more  advantageously  be  taken  in  meat, 
butter,  oil  and  cheese.  On  the  other  hand,  fat  having  been 
removed,  the  chief  value  of  the  milk  to  the  diabetic  patient 
is  lost.    The  percentage  of  sugar  in  sour  milk  is  not  much 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     133 

less  than  in  fresh  milk.  Recently,  sugar-free  milks'  have 
been  put  upon  the  market  on  a  large  scale,  and  many  of  my 
patients,  particularly  children,  have  found  them  of  distinct 
advantage.  These  preparations  of  diabetic  milk  will  keep 
from  one  to  three  weeks,  and  are  consequently  of  great 
value  to  patients  when  travelling.  As  a  rule  they  are  -con- 
centrated one-half.  Consequently  tliey  should  be  diluted 
before  being  used.  They  are  so  valuable  for  diabetic  patients 
that  one  should  always  encourage  their  use  in  small  quantities 
at  first,  so  that  the  patient  can  become  accustomed  to  the 
artificial  taste  and  can  determine  the  form  in  which  the  milk 
is  most  agreeable  to  him.  This  is  often  as  equal  parts  of  milk 
and  Vichy  Celestin. 

Williamson-  suggested  the  following  rule  for  the  manu- 
facture of  artificial  milk:  "To  about  a  pmt  of  water,  placed 
in  a  large  drinking  pot  or  tall  vessel,  three  or  four  tablespoon- 
fuls  of  fresh  cream  are  added  and  well  mixed.  The  mixture 
is  allowed  to  stand  from  twelve  to  twenty-four  hours,  when 
most  of  the  fatty  matter  of  the  cream  floats  to  the  top;  it 
can  be  skimmed  off  with  a  teaspoon  easily,  and  upon  examina- 
tion it  will  be  found  practically  free  from  sugar.  This  fatty 
matter  thus  separated  is  placed  in  a  glass."  The  white  of  an 
egg  is  added  to  it  and  the  mixture  well  stirred.  Then  dilute 
with  water  until  a  liquid  is  obtained  which  has  the  exact 
color  and  consistency  of  ordinary  milk.  "If  a  little  salt  and  a 
trace  of  saccharin  be  added  a  palatable  drmk,  practically 
free  from  milk-sugar,  is  produced  which  has  almost  the  same 
taste  as  milk,  and  which  contains  a  large  amount  of  fatty 
material.  With  very  little  practice  the  right  proportions 
can  be  easily  guessed,  and  of  course  much  larger  quantities 
can  be  employed  (in  order  to  prepare  a  considerable  amount 
of  the  drink  at  one  time)  than  those  mentioned  above." 

Rennet  may  be  made  from  milk,  but  unless  the  curd  is 
carefully  washed  it  will  contain  2  to  2.5  per  cent,  lactose. 
When  the  rennet  is  made  from  cream  the  lactose  is  materially 
diminished.     Kefir   contains   approximately   2.4  per   cent. 

ID.  Whiting  &  Sons,  Boston. 

2  Williamson:  Diabetes  Mellitus  and  its  Treatment,  Macmillan  Company, 
1898,  p.  334. 


134    DIETETIC  SUGCESTIOXS,  RECIPES  AND  MENUS 

niilk-suirar.     ^  on  Noordcn  says  this  milk  ]ias  also  been  of 
great  help  in  the  treatment  of  diabetes  in  children. 

Lawrence  Litchfield,  of  Pittsburgh,  gi\es  whijiped  cream 
to  his  patients  made  according  to  the  following  rule:  Add 
two  ounces  of  40  per  cent,  cream  to  a  i)int  of  cold  water  in 
a  Mason  jar  and  have  it  shaken  vigorously  imtil  the  cream 
is  thoroughly  "whipped."  Sometimes  a  trace  of  saccharin  is 
added,  usually  not.  "  ]\ry  patients  like  to  eat  this  with  a  spoon, 
but,  of  coiu'se,  it  can  be  used  in  any  way  that  is  desired.  It 
contains  only  a  trace  of  sugar."  The  fermented  milks  con- 
tain about  half  as  much  carbohydrate  as  ordinary  milk. 

RECIPES. 

]\Iany  books  have  been  written  containing  recipes  for  dia- 
betic patients.  With  modern  methods  of  treatment,  however, 
most  of  these  rules  are  worthless  for  severe  dia}:»etic  patients 
because  of  their  high  content  of  protein  and  fat.^  In  general 
such  patients  prefer  and  should  be  encouraged  to  take  simple, 
natural  foods  rather  than  artificial  ones. 

The  mild  cases  of  diabetes  need  no  special  recipes.  Des- 
serts can  often  be  made  w' ith  gelatin,  and  this  may  be  flavored 
with  coffee,  lemon,  rhubarb,  cocoa  shells  or  cracked  cocoa. 
In  preparing  such  desserts,  if  saccharin,  is  used  it  should  be 
added  as  late  as  possible  during  the  cooking,  for  it  is  apt  to 
become  bitter  with  heat.  It  is  always  a  safe  rule  to  add  too 
little  rather  than  too  much  saccharin.  Usually  one  need 
pay  little  attention  to  the  quantity  of  protein  in  the  gelatin, 
because  the  ordinary  portion  of  jelly  contains  only  about  2.5 
grams.  One  of  my  patients  on  a  very  rigid  diet  so  enjoyed 
the  bulk  of  the  gelatin  as  to  take  10  grams  daily.  She  accom- 
plished this  by  having  the  jelly  made  very  thick. 

DIABETIC  BREAD  OR  BISCUITS. 

1  Box  Lister's  Diabetic  Flour 
3  Eggs 

Method. — Separate  whites  and  yolks  of  eggs.  Add  to 
whites  salt  to  taste.     Beat  whites  until  very  thick.     Beat 

1  The  patient  must  invariably  allow  in  the  total  diet  for  the  quantities  of 
carbohydrate,  protein  and  fat  which  he  has  had  in  any  given  recipe. 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     135 

yolks  until  thick  and  lemon  colored.  Combine  and  beat 
with  egg-beater.  Fold  in  gradually  one  box  of  Lister's 
Diabetic  Flour.  Bake  in  tin  5  inches  long,  3  inches  wide 
and  3  inches  high  (straight  sides) .  Have  oven  hot.  If  baked 
in  gas-stove  oven,  bake  for  fifteen  minutes,  full  heat,  then 
reduce  heat  one-half  for  ten  minutes  longer.  If  baked  in 
coal  or  wood  oven,  bake  from  fifteen  to  thirty  minutes.-  Do 
not  remove  from  tin  until  partly  cooled.  Each  loaf  contains 
protein,  58  grams;  fat,  18.6  grams;  calories,  397.  If  desired 
this  may  be  made  into  biscuits.  The  bread  or  biscuits  may 
be  flavored  with  nutmeg  or  cloves.^ 

DIABETIC  NOODLES. 

METHOD. — To  the  well-beaten  yolks  of  two  eggs,  add  two 
tablespoonfuls  of  warm  water  and  a  little  salt.  Slowly 
stir  in  one  box  of  Lister's  Diabetic  Flour.  Knead  and  roll 
on  pie-board.  When  almost  dry,  roll  and  cut  fine.  Dry 
thoroughly. 

DIABETIC  MUFFINS. 

1  Box  Lister's  Diabetic  Flour 
lEgg 

3  Tablespoonfuls  of  sweet  heavy  cream  (40  per  cent,  cream) 

2  Tablespoonfuls  of  bacon  fat 

Same  quantity  of  butter,  melted  lard  or  Crisco  may  be 
used  in  place  of  bacon  fat.  This  will  make  eight  muffins, 
each  muffin  having  food  value  equivalent  to  one  egg  (or 
protein,  6  grams;  fat,  6  grams;  calories,  78). 

Method. — Beat  white  of  egg  very  stiff;  beat  yolk 
separately  from  white;  to  the  beaten  yolk  add  the  cream 
and  beat;  then  add  bacon  fat  (butter,  melted  lard  or  melted 
Crisco) ;  beat  again,  then  add  the  beaten  white  of  egg;  lastly 
the  flour,  beating  the  mixture  all  the  while  the  flour  is  slowly 
added.  Put  in  buttered,  hot  muffin  irons  and  bake  for  ten 
to  twenty  minutes.  If  coal  range  is  used,  bake  for  fifteen 
minutes  and  have  the  oven  hot.  Use  old-fashioned  cast-iron 
muffin  iron, 

1  Clove,  mustard,  cayenne  are  free  from  starch.  White  pepper,  cinna- 
mon and  ginger  contain  much  starch. 


130     DIETETIC  SUGCfESTIOXS,   RECIPES  AND  MENUS 

LISTER'S  FLOUR  AND  BRAN  MUFFINS. 
(Useful  in  Diabetic  Constipation.) 

1  Level  tablespoonful  lard,  Imcon  fat,  butter  or  Crisco 

lEgg 

1  Cupful  washed  brau 

1  Package  Lister's  Flour 

^  Cupful  water  or  less 

Tie  dry  bran  in  cheesecloth  and  soak  one  hour.  AVash  by 
squeezing  water  through  and  tlirough.  Change  water  sev- 
eral times;  wring  dry.  Separate  egg  and  beat  thoroughly. 
Add  to  the  egg  yolk  the  melted  lard  and  beaten  egg  white. 
Add  Lister's  Floiu*,  washed  bran  and  water.  Make  nine 
muffins. 

DIABETIC  COOKIES. 

1  Box  Lister's  Diabetic  Flour 

1  Egg 

3  Tablespoonfuls  of  cream 

3  Tablespoonfuls  of  butter  or  bacon  fat 

Method. — Beat  egg  until  light.  Add  cream  and  beat 
again.  Add  butter  and  beat  again.  Then  add  Lister's 
Flour  slowly.  A  little  caraway  seed,  ginger  or  vanilla  may 
be  added  to  suit  the  taste.  Roll  very  thin  and  only  a  small 
amount  at  a  time.    Bake  in  hot  oven  about  ten  minutes. 

Makes  thirty  cookies  of  about  23  calories  each. 

FRENCH  TOAST. 

1  Egg 

2  or  3  tablespoonfuls  cream 
Lister's  Muffins,  Biscuits  or  Bread 

Beat  the  egg  and  cream  together.  Slice  Lister's  Muffins, 
Biscuits  or  Bread.  Soak  the  slices  in  the  egg  and  cream  and 
fry  in  a  little  hot  butter  until  light  brown. 

Follow  all  directions  exactly  as  given.  The  batter  may 
appear  to  be  too  thick  or  heavy,  but  no  more  moisture  should 
be  added  than  is  called  for  in  these  directions. 


DIETETIC   SUGGESTIONS,   RECIPES  AND   MENUS     137 

BAKED  SOY  BEANS. 

Yellow  Soy  beans,  120  grams,  are  soaked  for  forty-eight 
hours,  then  boiled  for  about  half  an  hour  and  finally  baked 
with  30  grams  pork  for  twelve  hours.  The  food  value  is 
approximately  as  follows: 


Carbo- 

hydrate, 

Protein, 

Fat, 

grams. 

grams. 

prams. 

Soy  beans,  120  grams 

.      .      .     0 

48 

24 

Pork,  30  grams       .... 

...     0 

4 

12 

Baked  Soy  Beans  and  Pork  ....  0       52       36 

SEA  MOSS. 

Sea  moss  farina  and  Irish  moss  are  usually  allowable  for 
diabetic  patients.  Most  of  the  carbohydrate  in  these  mate- 
rials is  in  the  form  of  pentosans  and  galactans,  which  Swartz^ 
has  shown  to  be  quite  inert  in  the  body.  Unfortunately 
these  products  are  sometimes  adulterated  with  other  carbo- 
hydrates. This  emphasizes  the  fact  that  no  matter  how 
useful  a  food  may  be  in  itself,  one  must  always  be  on  the 
lookout  for  adulteration. 

HEPCO  CAKES. 

So  arranged  that  one  cake  is  equivalent  to  an  egg. 

Protein.  Fat. 

Hepco  flour,  140  grams 60  29 

Eggs  (2) 12  12 

Cream,  40  per  cent.,  60  c.c 2  24 

Butter,  10  grams 9 

74  74 

Make  twelve  cakes.  Each  cake  contains  6  grams  protein, 
6  grams  fat  and  approximately  75  calories. 

BRAN  BISCUITS  FOR  CONSTIPATION. 

The  following  rule  was  given  me  by  Dr.  F.  M.  Allen: 

Bran 60  grams 

Salt i  teaspoonful 

Agar-agar,  powdered    .........  6  grams 

Cold  water ,  100  c.c.  (5  glass) 

»  Swartz:    Tr.  Conn.  Acad.  Arts  and  Sc,  1911,  xvi,  p.  247. 


138     DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS 

Tie  bran  (for  character  of  bran  to  purchase  see  p.  131)  in 
cheesecloth  and  wash  under  cold  water  tap  until  water  is 
clear.  Bring  agar-agar  and  water  (100  c.c.)  to  the  boiling- 
point.  Add  to  washed  bran  the  salt  and  agar-agar  solution 
(hot).  ]\Iold  into  two  cakes.  Place  in  pan  on  oiled  paper 
and  let  stand  half  an  hour;  then,  when  firm  and  cool,  bake 
in  moderate  o\-en  thirt>'  to  forty  minutes. 

The  bran  nnifHns  naturally  will  be  far  more  palatable  if 
butter  and  eggs  are  added.  This  may  be  done  provi<ling 
the  patient  allows  for  this  in  the  diet.  If  the  patient  is  not 
upon  a  measured  diet,  then  considerable  latitude  can  be 
employed  in  making  the  bran  cakes. 

NEW  ENGLAND  DEACONESS  HOSPITAL  RECIPE. 

Bran 100  grams 

Powdered  agar-agar 20       " 

Pinch  of  salt. 

Tie  bran  loosely  in  a  piece  of  cheesecloth  and  soak  twelve 
hours.  Wash  until  clear;  add  dry  agar-agar  and  salt.  Pack 
firmly  into  muffin  pans  oiled  with  mineral  oil.  Bake  three- 
quarters  of  an  hour  or  more  in  a  slow  oven. 

BRAN  CAKES  FOR  DIABETICS. 

Carbo- 
Protein,         Fat,        hydrate, 
Food.  Amount.  grams.        grams.        grams.      Calories. 

Bran       ...  2  cupfuls 

Melted  butter   .  30  grams  .  .  25  .  .  225 

Eggs  (whole)  2                 12  12  .  .  156 

Egg  white  (1)    .  25  grams  3  .  .  .  .  12 


Salt  ....        1  teaspoonful 
Water 


15  37  0  393 


Tie  bran  in  cheesecloth  and  wash  thoroughly  by  fastening 
on  to  the  water  tap  until  the  water  comes  away  clear.  The 
bran  should  be  frequently  kneaded  so  that  all  parts  come  in 
contact  with  the  water.  Wring  dry.  Mix  bran,  well-beaten 
whole  eggs,  butter  and  salt.  Beat  the  egg  white  very  stiff 
and  fold  in  at  the  last.    Shape  with  knife  and  tablespoon  into 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     139 

three  dozen  small  cakes.  If  desired  one-half  gram  of  cinna- 
mon or  other  flavoring  may  be  added.  Each  cake  contains: 
protein,  0.5  gram;   fat,  1  gram;   calories,  11. 

CRACKED  COCOA. 

Cracked  cocoa  (cocoa  nibs)  makes  a  most  useful  drink 
for  diabetic  patients.  This  is  not  generally  appreciated  by 
the  profession. 

The  sample  of  cracked  cocoa  (cocoa  nibs)  used  has  been 
purchased  of  the  S.  S.  Pierce  Co.,  Boston.  It  was  analyzed 
by  Professor  Street,  with  the  following  result: 

Moisture 2.83 

Protein 14.69 

Fat 51.42 

Fiber 4.32 

Ash 3.88 

Starch 7.48 

Reducing  sugar,  as  dextrose,  direct none 

Reducing  sugar,  as  dextrose,  after  inversion       .      .      .      .  0.94 

The  cocoa  is  prepared  for  the  table  by  adding  a  cupful  of 
the  cracked  cocoa  to  a  quart  of  water  and  letting  it  simmer 
on  the  back  of  the  stove  all  day,  adding  water  from  time  to 
time. 

Professor  Street  was  good  enough  to  analyze  the  infusion, 
and  wrote  me:  "The  cocoa  prepared  according  to  dii'ections 
contained  0.032  per  cent,  of  reducing  sugar  as  dextrose 
direct  and  0.138  per  cent,  of  total  reducing  sugars." 

Cocoa  shells  may  be  prepared  in  the  same  way,  but  1  to  1| 
cups  will  be  required  to  one  quart  of  water  A  mixture  of 
equal  parts  cracked  cocoa  and  cocoa  shell  may  also  be  used. 

The  cracked  cocoa  should  be  strained  before  serving,  other- 
wise the  cocoa  nibs  might  be  eaten  and  the  carbohydrate  in 
these  would  not  be  negligible. 

AGAR-AGAR  JELLY. 

One-eighth  to  one-quarter  of  an  ounce  is  sufficient  to  make 
one  quart  of  jelly.  The  agar-agar  is  added  to  the  boiling 
water.  After  it  is  thoroughly  dissolved  and  cooking  com- 
pleted, flavoring  extract,  coloring  matter  and  saccharin  are 
added  as  desired.     Agar-agar  may  also  be  added  to  broths. 


140    DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS 

Miss  K.  Grace  IMc('ull()u<ili,  Dietitian  at  tlie  Peter  Bent 
Brigham  IIosi)ital,  has  given  nie  several  practical  sujifi^estions 
ahont  the  pre])arati()n  <il'  h<)s))ital  diabetic  diets.  JMany  of 
these  lun-e  heen  iiicorporatrd  in  wliat  follows. 

THRICE  COOKED  VEGETABLES. 

The  \egetables  are  cleaned,  cut  ii])  fine,  soaked  in  cold 
water  and  then  strained.  ^J'he  \('getables  are  then  tied  up 
loosely  in  a  large  scpiarc  of  double  cheesecloth — large  enough 
so  that  the  corners  of  the  cloth,  after  it  has  been  tied  up 
with  a  string,  make  conveniently  long  ends,  and^  also  large 
enough  to  allow  the  vegetables  to  swell  without  sticking 
together.  They  are  then  transferred  to  fresh  cold  water, 
placed  on  the  fire  and  brought  to  the  boiling-point,  at  which 
temperature  they  are  maintained  for  from  three  to  five  min- 
utes. This  water  is  then  poured  ofY  and  replaced  by  fresh, 
and  the  vegetables  again  boiled  a  sunilar  length  of  time. 
Three  changes  of  water  are  usually  sufficient  to  remove  the 
carbohydrate,  as  has  been  proved  by  Professor  Wardall's 
preliminary  experiments.  The  pots  for  the  vegetables  should 
be  of  sufficient  size  to  hold  a  large  quantity  of  water,  and 
in  a  hospital,  vegetables  enough  for  the  daily  supply  of  six 
patients.  Vegetables  thus  cooked  wall  keep  in  cold  storage 
two  or  more  days,  and  reheating  them  in  a  steamer  is  a  simple 
affair. 

If  the  ^'egetables  are  cooked  with  the  cover  left  off  the 
pot  they  will  be  lighter  in  color  and  the  fia^'or  not  so 
strong. 

jNIiss  jNIcCullough  has  adopted  several  expedients  by  which 
variety  in  the  5  per  cent,  vegetables  is  obtained,  and  thus  the 
monotony  of  the  diet  avoided.  She  suggests  that  the  large 
outer  stalk — slightly  green  covering — of  cauliflower  be  care- 
fully cleaned,  cut  into  half -inch  pieces  and  boiled  until  tender, 
and  frequently  this  is  transferred  from  four  waters.  Similarly 
the  green  outside  leaves  and  any  small  pieces  of  lettuce  may 
be  shredded  and  served  like  spinach.  Chard  in  season  can  be 
purchased  by  the  bushel,  cut,  and  then  chopped  up.  Rhu- 
barb retains  its  acid  flavor  and  has  proved  so  acceptable  an 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     141 

addition  to  the  diet  that  in  the  future  it  should  be  canned  by 
the  cold-water  method  for  subsequent  use.  The  flat,  large, 
celery  stalks  with  any  or  all  the  leaves,  whether  yellow  or 
green,  chopped  fine,  serve  excellently  well.  White,  green  and 
red  cabbage  is  cut  fine  and  served  as  cole-slaw. 

Diabetic  patients  should  be  urged,  whenever  possible,  to 
have  a  garden  and  to  raise  suitable  vegetables  for  themselves 
for  the  ensuing  winter.  One  of  my  patients  does  this  and 
thus  provides  himself  with  the  best  of  celery,  cabbage,  lettuce, 
etc.  This  patient  eats  a  slice  of  cabbage  cut,  as  one  buys 
cheese  in  a  grocery  store,  for  breakfast  each  morning,  and 
by  this  means  keeps  the  bowels  perfectly  regular. 

Canned  vegetables  which  have  been  of  the  most  service 
at  the  Peter  Bent  Brigham  Hospital  are  of  four  varieties: 
soup  asparagus,  broad,  flat,  cut  string  beans,  the  tender, 
green,  stringless  bean  and  the  white  wax  beans.  The  pods 
are  separated  from  the  beans,  the  latter  being  used  for  the 
benefit  of  other  patients.  Soup  asparagus  proved  to  be 
excellent  for  hospital  use.  It  is  a  by-product  of  the  factory 
and  consists  of  the  broken-off  tips  and  the  shorter,  thin  stalks 
which  are  unfit  for  the  standard  size.  The  pieces  are  about 
one.  inch  long  and  are  all  edible. 

SQUAB. 

A  squab  when  carefully  boned  yields  50  grams  of  meat. 
This  is  broiled  in  an  oiled  paper  case  to  prevent  evaporation, 
and  when  served  with  the  escaped  juices  proves  a  favorite 
dish  for  patients.  It  contains  about  12  grams  protein  and 
5  grams  fat. 

BOILED  DINNER. 

Corned  beef,  with  cabbage  and  one  other  vegetable,  served 
together  as  a  boiled  dinner,  is  most  acceptable  to  male 
patients.  A  portion  containing  50  to  75  grams  of  meat  and 
100  grams  of  each  vegetable  makes  an  excellent  meal. 
Corned-beef  hash  made  of  meat  and  vegetables  in  the  same 
proportion  could  also  be  served  for  variety. 


142     DIETETIC  SUGGESTIOXS,   h'ECIl'ES  AND  MENUS 

SEASONING. 

The  proper  seasoning  of  tlic  food  is  a  great  help  to  the 
diabetic  patient.  So  many  articles  are  excluded  from  the 
diet  that  the  great  \-ariety  which  is  possible  in  the  iire])ara- 
tion  of  the  food  by  the  help  of  seasoning  is  o\erlo()ked. 
Horseradish,  to  be  sm'e,  contains  10  per  cent,  of  carbohydrate, 
but  it  would  take  at  least  two  teaspoonfuls  to  contain  a 
gram,  and  probably  far  more.  Sour  pickles  are  allowable, 
and  other  pickles  made  from  the  grouj)  of  ")  ])er  cent,  \ege- 
tables,  provided  one  is  assured  that  they  have  been  prepared 
without  sweetening.  Mint,  capers,  curry,  tarragon  vinegar, 
onion,  bay  leaf  and  cloves  may  all  be  used  as  seasoning;  tomato 
stewed  with  onion,  bay  leaf  and  cloves,  and  thickened  with 
Irish  moss,  may  be  served  as  a  sauce. 

DIABETIC  MENUS. 

Patients  naturally  differ  in  their  likes  and  dislikes.  Case 
No.  S6G  arranged  his  diet,  which  contained  carbohydrate  39 
grams,  protein  84  grams  and  fat  81  grams  essentially  as  shown 
in  Table  39.  Using  this  as  a  basis,  Miss  Alice  M.  Dike,  of 
Simmons  College,  has  arranged  the  following  menus  and 
appended  various  useful  recipes: 

Table  39. — The  Diet  of  Case  No.  866  with  Modifications  for 

One  Week. 

Carbo- 
Amount.  hydrate.       Protoin.         Fat. 

5  per  cent,  vegetables      .      .  900  gm.  30  15  0 

Eggs 2  0  12  12 

Bacon 30  gm.  0  5  15 

Meat 180  gm.  0  48  30 

20  per  cent,  cream      .            .  120  gm.  4  4  24 

Strawberries 75  gm.  5  0  0 

39  84  81 

FIRST  DAY  (TYPICAL). 

Breakfast. 

Fried  eggs,  2;  bacou,  30  grams. 

Stewed  tomato,  150  grams;  string  beans,  150  grains. 

Coffee  with  cream,  30  grams. 

Bran  muffin. 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     143 
Lunch. 

Broth. 

Baked  haddock,  90  grams. 

Boiled  cabbage,  150  grams;  lettuce  and  cucumbers,  150  grams. 

Coffee  jelly,  cream,  30  grams. 

Tea,  cracked  cocoa  or  cocoa  shells,  cream,  30  grams. 

Bran  muffin. 

Dinner, 

Broth. 

Roast  beef,  90  grams. 

Asparagus,  150  grams;  cold  slaw,  150  grams. 

Strawberries,  75  grams;  cream,  30  grams. 

Coffee. 

Bran  muffin. 

SECOND  DAY. 

In  the  following  menus,  unless  otherwise  stated,  one  bran 
muffin,  40  grams  of  cream,  and  tea,  coffee,  cracked  cocoa  or 
cocoa  shells  are  served  at  each  meal.  Broth  may  also  be 
served.  If  cream  is  used  in  the  preparation  of  any  dish,  or 
is  served  with  it,  the  amount  is  deducted  from  that  allowed 
for  the  day.  In  every  case  45  grams  are  allowed  per  day  for 
beverages. 

Breakfast. 

Liver,  60  grams;  bacon,  15  grams. 

String  beans,  150  grams;  spinach,  150  grams. 

Lunch. 

Omelet  (eggs  2)  with  chopped  ham,  30  grams. 
Cabbage,  150  grams;  radishes,  90  grams. 
Rhubarb  jelly,  60  grams. 

Dinner. 

Hamburg  steak,  90  grams;  bacon,  15  grams. 
Swiss  chard,  150  grams;  sauerkraut,  150  grams. 
Orange,  50  grams. 

THIRD  DAY. 
Breakfast. 

Eggs  (I5)  scrambled  with  tomato,  60  grams;  bacon,  30  grams. 
String  beans,  150  grams;  sliced  cucumber,  90  grams. 


144    DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS 

Lunch. 

Tuna  fish  salad  [fish,  90  grams;  lettuce,  oO  grams;  boiled  dressing  (crean) 

60  grams;  egg,    \)\. 
Brussels  sprouts,  150  grams;  boiled  cucumbers,   120  grams. 
Peach,  37  grams. 

Dinner. 

Corned  beef,  90  grams;  cabbage,  200  grams. 
Stewed  rhubarb,  100  grams. 
Cocoa  shells  jelly. 

FOURTH  DAY. 

Breakfast. 

Soft  boiled  egg  (1);  bacon,  30  grams. 

Baked  tomatoes,  150  grams;  string  beans,  150  grams. 

Lunch. 

Cold  beef,  90  grams;  grated  horseradish. 

String  beans,  200  grams;  artichoke  salad,  100  grams. 

Raspberries,  37  grams. 

Dinner. 

Chicken,  90  grams. 

Stewed  okra  and  tomato,  200  grams;  celery.  100  grams. 

Coffee;  Spanish  cream  (egg,  1;  cream,  30  grams). 


FIFTH  DAY. 
Breakfast. 

Orange,  50  grams. 

Shirred  egg  (egg,  1;  cream,  15  grams);  bacon,  20  grams. 

String  beans,  150  grams;  spinach,  150  grams. 

Lunch. 

Hash   (corned  beef,   90  grams;  cabbage,   180  grams;     leeks,    GO  grams   or 

onions,  30  grams;  bacon,  10  grams). 
Lettuce,  60  grams. 
Coffee  jelly  whip  (white  of  one  egg). 

Dinner. 

Lamb  chops,  90  grams;  tomato  sauce,  60  grams. 

Asparagus,  120  grams;  dandelion  greens,  120  grams;  and  bacon,   10  grams. 

Baked  custard  (yolk  of  1  egg;  cream,  30  grams). 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     145 

SIXTH  DAY. 
Breakfast. 

Scrambled  eggs  (1  and  1  egg  white);  dried  beef,  30  grams;  bacon,  30  grama. 
Cauliflower,  150  grams;  string  beans,  150  grams. 

Lunch. 

Spinach  soup  (spinach,  60  grams;  cream,  30  grams;  egg  yolk,  1). 

Broiled  finnan  haddie,  60  grams. 

Boiled  celery,  150  grams;  cabbage,  90  grams. 

Coffee  jelly. 

Dinner. 

Steak,  90  grams;  water  cress,  60  grams. 

Summer  squash  or  vegetable  marrow,  150  grams;  baked  tomato,  90  grams. 

Blackberries,  37  grams. 

SEVENTH  DAY. 
Breakfast. 

Scalloped  fish,  90  grams;  bacon,  15  grams. 
String  beans,  200  grams;  radishes,  100  grams. 

Lunch. 

Egg  salad  (egg,  2;  lettuce,  30  grams);  bacon,  15  grams. 
Boiled  leeks,  150  grams;  beet  greens,  120  grams. 
Irish  moss  blanc  mange  (cream,  75  grams). 

Dinner. 

Broiled  swordfish,  90  grams. 

Fried  egg  plant,  150  grams;  tomato  jelly  salad  (tomato,  120  grams;  lettuce, 

30  grams). 
Blueberries,  37  grams. 

PICNIC  LUNCHES. 
FIRST  DAY. 

(The  amounts  used  must  be  deducted  from  the  day's  total.) 

Dinner. 

Cold  chicken,  60  grams. 
Asparagus,  200  grams;  cucumber,  100  grams. 
Baked  custard  (egg,  1;  cream,  60  grams). 
10 


146    DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS 

Supper. 

Sardines,  90  grams. 

Lettuce,  100  grams;  ripe  tomatoes,  200  grams. 

Cofifee  jeiiy. 

SECOND  DAY. 

Dinner. 

Veal  (60  grams)  loaf  with  lianl  boiled  egg  (1). 
Endive,  100  grams;  string  tjeans,  200  grams. 
Cocoa  shells  jelly. 

Supper. 

Cold  ham,  90  grams. 

Asparagus,  180  grams;  leek  (90  grams)  and  lettuce  (30  grams)  salad. 

Orange,  50  grams. 

RECIPES.i 
Meat  Broth. 

1  pound  (3  parts  lean  meat  and  1  part  bone). 
1  quart  cold  water. 
1  teaspoonful  salt. 

Cut  or  chop  the  meat  fine,  removing  all  fat,  add  cold 
water  and  let  stand  one  hour,  heat  slowly  to  the  boiling- 
point,  simmer  four  or  more  hours,  strain,  add  salt,  and  water 
to  make  up  the  one  quart;  cool.  Remove  fat  carefully, 
reheat  and  serve.- 

A  double  boiler  is  convenient  for  cooking  small  quan- 
tities of  broth.  Sweet  herbs  (thyme,  marjoram,  summer 
savory),  parsley,  celery  seed,  bay  leaf,  peppercorns,  cloves 
and  any  of  the  5  per  cent,  vegetables  may  be  used  for  season- 
ings. If  vegetables  are  served  in  the  broth  the  amount 
must  be  deducted  from  the  day's  allowance. 

Broth  may  be  thickened  with  egg  yolk  or  Irish  moss.  (See 
Cream  Soups.) 

>  See  footnote  page  134. 

-  For  composition  of  soups,  broths  and  bouillons  see  pages  158  and  159. 
Unless  very  thin  broths  or  bouillons  are  employed  an  allowance  for  food 
value  must  be  made. 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     147 
Clam  and  Oyster  Broth. 

J  cup  clams  or  oysters  and  their  liquor. 

1  cup  cold  water. 

Celery  seed,  blade  of  mace,  if  liked. 

Chop  the  carefully  washed  clams  or  oysters,  add  liquor 
and  water,  bring  slowly  to  the  boiling-point,  strain  and 
add  salt  if  necessary.  Cream,  plain  or  whipped,  may  be 
added  just  before  serving. 

Cream  Soups. 

1  cup  puree  [cooked  and  strained  vegetables,  60  to  120  grams  (see 
below)  and  broth,  cream  or  water  in  which  vegetable  was  cooked 
to  make  1  cup]. 

i  teaspoonful  salt. 

Pepper. 

1  egg  yolk. 

Heat  the  puree  to  the  boiling-point,  add  slowly  to  the 
beaten  egg  yolk,  beating  constantly,  add  salt  and  serve 
immediately,  or  place  in  double  boiler,  cook  one  minute, 
stirring  constantly;  add  salt  and  serve  immediately.  The 
mixture  will  curdle  if  not  stirred  carefully  or  if  over- 
cooked. 

If  preferred  a  small  piece  of  Irish  moss  washed  and  soaked 
ten  minutes  may  be  cooked  with  the  puree  to  thicken  it  in 
■  place  of  egg. 

Asparagus,  60  grams. 

Celery,  60  grams  and  small  blade  of  mace. 
CauUflower,  60  grams. 
Spinach,  60  grams  and  bit  of  bay  leaf. 
Leek,  60  grams. 

Tomato,  120  grams;  and  bit  of  bay  leaf,  2  cloves,  J  teaspoonful  chopped 
chives. 

Scalloped  Fish. 

Flake  any  cooked  fish,  moisten  with  broth,  tomato  or 
cream,  season,  place  in  baking  dish  and  cover  with  bran 
muffin  dried  and  crumbled  fine.  Meat,  hard-boiled  eggs 
or  vegetables  may  be  prepared  in  the  same  way. 


148    DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS 

Fried  Fish. 

Dry  whole  small  fish,  or  pieces  suitable  for  serving,  rub 
with  mineral  oil  and  coat  with  crumbs  prepared  as  for 
scalloped  fish.  Fry  in  mineral  oil  or  bake  in  a  hot  oven. 
Tomato  cut  in  thick  slices  may  be  prepared  in  the  same  way. 

Eggs. 

Any  of  the  regular  recipes  for  cooking  eggs  may  be  used 
if  water,  cream,  tomato  or  broth  is  used  in  place  of  milk 
and  the  butter  is  omitted  or  mineral  oil  substituted  for  it. 

French  Dressing. 

8  teaspoonful  salt.  1  teaspoonful  vinegar. 

Pepper.  1  tablespoonful  mineral  oil. 

Mix  in  the  order  given,  chill  and  beat  or  shake  in  a  stop- 
pered bottle  until  thick.     Serve  immediatel}'. 

Boiled  Dressing. 

1  teaspoonful  salt.  I  cup  cream  or  cream  and  water. 

Pepper.  2  tablespoonfuls  vinegar. 

1  egg  or  2  egg  yolks. 

IMixed  in  the  order  given,  adding  the  vinegar  slowly  to 
the  other  ingredients,  cook  over  hot  water  until  thickened, 
stirring  all  the  time;  chill,  strain  and  serve. 

Tomato  Jelly  Salad. 

The  proportions  given  are  for  use  with  granulated  gelatin ; 
if  powdered  gelatin  is  used  a  little  more  may  be  required. 

2  teaspoonfuls  gelatin.  240  grams  stewed  and  strained 
2  tablespoonfuls  cold  water.  tomato. 

J  teaspoonful  salt. 

Soak  the  gelatin  in  the  cold  water  ten  minutes,  dissolve 
in  the  hot  tomato,  season,  mold  and  chill.  A  bit  of  bay  leaf, 
two  cloves  and  a  slice  of  leek,  or  a  few  chopped  chives,  may 
be  stewed  with  the  tomato. 


DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS     149 
Cucumber,  Radish  or  Celery  Jelly  Salad. 

2  teaspoonfuls  gelatin.  \  teaspoonful  salt. 

2  tablespoonfuls  cold  water.  60  grams  or  more  chopped  vegetable. 

2  tablespoonfuls  vinegar  and  water  or  both  to  make  1  cup. 

Mix  like  tomato  jelly  salad,  adding  the  vegetable  just 
before  pouring  into  the  mold.  Chopped  mint  may  be  used 
in  place  of  vegetable. 

Horseradish  Sauce. 

2  teaspoonfuls  grated  horseradish         Cayenne. 

i  teaspoonful  vinegar.  1  tablespoonful  cream. 

i  teaspoonful  salt. 

Mix  the  first  four  ingredients  and  add  to  the  cream  beaten 
stiff.     Serve  immediately. 

It  is  unfortunate  that  horseradish  is  occasionally  adultera- 
ted with  a  10  per  cent,  vegetable — turnip. 

Cucumber  Sauce. 

Grate  60  grams  cucumber,  drain  and  season  with  salt, 
pepper  and  vinegar. 

Tomato  Sauce. 

Stew  60  grams  of  tomato  with  salt,  pepper,  cloves,  bay 
leaf  and  chives.  Strain.  Irish  moss  may  be  cooked  with 
tomato  for  thickening. 

Mint  Sauce. 

2  tablespoonfuls  finelj'^  chopped  mint  leaves. 
I  cup  vinegar.  Saccharin. 

Pour  vinegar  on  the  mint  and  let  stand  thirty  minutes, 
add  saccharin  and  serve. 

Jellies. 

The  following  jellies  are  made  by  dissolving  2  teaspoonfuls 
gelatin  soaked  in  2  tablespoonfuls  cold  water  in  any  of  the 
liquids  given  below  which  should  be  boiling  hot  when  meas- 
ured and  added;  stir  well,  add  saccharin  to  taste  and  flavor- 
ing, strain  and  chill. 


150     DIETETIC  SUGGESTIOXS,    h'KCI I'I'S   AM)   MENUS 

Liquid. 

1  cup  coffee. 

1  cup  cracked  cocoa  or  cocoa  sliells  infusion. 

120  grams  stewed  and  strained  rhubarb  or  cranberrios,  water  to  fill  cup. 

120  grams  cream,  water  to  fill  cup. 

1  cup  water. 

Any  fruit  extract,  grated  rind  of  orange  or  lemon,  dry  or  green  ginger 
root,  not  crj'stallized  ginger,  or  mint  leaves  boiled  in  water  to  taste, 
mint  or  wintergreeu  extract. 

2-4  drops  almond  extract. 

i  teaspoonful  vanilla  extract. 

Custard. 

1  cup  cream  and  water.  Saccharin. 

1  egg  or  2  egg  yolks.  J  teaspoonful  vanilla. 

Salt. 

Heat  the  liquid  and  add  slowly  to  the  slightly  beaten  egg, 
stirring  constantly.  For  soft-boiled  custard,  place  in  a 
double  boiler,  cook  until  it  coats  the  spoon,  remove  and 
chill  promptly.  When  cool  strain  and  flavor.  For  baked 
custard  mix  all  the  ingredients,  pour  into  custard  cups  and 
bake  in  a  moderate  oven  until  jelly-like.     Chill  and  serve. 

Spanish  Cream. 

1  teaspoonful  gelatin.  1  egg  yolk. 

1  tablespoonful  cold  water.  Saccharin. 

6  tablespoonfuls  hot  coffee  and  Salt. 

cream  or  water  and  cream.  1  egg  white. 

Soak  gelatin  in  cold  water,  dissolve  in  hot  liquid,  pour 
mixture  on  egg  yolk  and  cook  like  soft-boiled  custard,  add 
saccharin  and  salt,  and  pour  while  still  hot  on  the  stiffly 
beaten  white  of  egg,  beating  constantly,  mold  and  chill. 

Irish  Moss  Blanc  Mange. 

1  cup  cream  and  water.  Salt. 

1  heaping  tablespoonful  Irish  moss.      J  teaspoonful  vanilla. 

Soak  the  moss  ten  minutes  in  cold  water,  drain,  add  to 
milk  and  cook  until  a  drop  jellies  on  a  cold  plate,  add  salt 
and  vanilla,  strain,  mold  and  chill. 

Ice-cream. 

Any  of  the  liquids  suggested  under  jellies  may  be  frozen 
for  ice-cream. 


CHAPTER  XVm. 
DIET  TABLES. 

The  improvement  in  the  treatment  of  diabetes  owes  much 
to  the  recent  dissemination  of  knowledge  regarding  the  com- 
position of  foods.  To  the  United  States  Government  we 
are  indebted  for  an  excellent  monograph  by  Atwater  and 
Bryant  entitled  "The  Chemical  Composition  of  American 
Food  Materials,"  Bulletin  No.  28,  revised  edition,  which  was 
first  issued  in  1906.  This  can  be  purchased  by  sending  ten 
cents  in  coin  to  the  Superintendent  of  Documents,  Washing- 
ton, D.  C.  From  this  have  been  abstracted  such  analyses  as 
are  especially  useful  in  the  diets  of  both  normal  and  diabetic 
individuals  and  have  computed  the  calories  per  100  grams 
instead  of  recording  the  same  per  pound. 

Analyses  are  also  inserted  published  by  the  Connecticut 
Agricultural  Ej^periment  Station.  Most  of  these  analyses 
are  concerned  with  the  so-called  diabetic  foods,  but  in  some 
cases  other  analyses  are  included  as  well.^  To  these  latter 
lists  the  value  of  protein  and  fat  have  been  added.  Whereas 
the  analyses  of  many  so-called  diabetic  foods  are  recorded,  no 
special  food  is  recommended.   In  general  the  cost  of  these  spe- 

1  "In  using  the  tables  of  the  Connecticut  Agricultural  Experiment 
Station  it  should  be  understood  that  the  percentages  in  the  protein  column 
are  uniformly  calculated  from  the  nitrogen  found,,  using  the  conventional 
factor  6.25.  With  pure  wheat  products  the  factor  5.7  gives  more  accurate 
results,  and,  strictly  speaking,  the  latter  factor  should  be  used  for  gluten 
flours  and  other  gluten  products.  In  baked  products  where  the  protein 
may  be  derived  from  other  sources  than  wheat,  such  as  soya  beans,  cotton 
seed,  nuts,  etc.,  it  is  impracticable  to  vary  the  factor  with  each  particular 
food  without  causing  endless  confusion.  Similarly,  it  has  seemed  to  the 
analysts  best  to  retain  for  the  flours  the  old  factor  for  the  sake  of  uniformity. 
In  the  high-grade  ground  glutens,  containing  as  much  as  13.7  per  cent,  of 
nitrogen,  the  use  of  the  proper  factor  would  reduce  the  protein  by  about 
7.5  per  cent.,  and  the  nitrogen-free  extract  would  be  increased  in  the  same 
proportion.  The  terms  "nitrogen-free  extract"  and  "carbohydrates"  are 
used  synonymously,  but  the  explanation  of  nitrogen-free  extract  in  the 
preceding  paragraph  should  be  borne  in  mind.  The  values  given  for  starch, 
however,  are  absolute,  being  direct  determinations  and  having  no  connec- 
tions with  the  protein  factor  used.  A  0  means  no  starch  was  found,  but 
a  blank  space  does  not  mean  the  same,  indicating  merely  that  starch  was  not 
tested  for."  (151) 


152  DIET  TABLES 

cial  foods  is  greater  than  tliat  of  the  common  foods  selected 
from  the  ordinary  diet;  in  fact,  tlie  ])atient  pays  for  tlie  taste. 
The  analyses  which  follow  apply  to  the  edible  portion  of 
the  food  in  question.  The  ai)pearan('e  of  a  blank  in  a  table 
does  not  indicate  that  the  particular  ingredient  is  missing. 
Whenever  a  range  in  composition  occurs  in  the  tables  the 
same  applies  to  carbohydrate  alone. 

Vegetables:  Fresh. 

Caloric 

Carbo-       value 

Protein,        Fat,       hydrates,   per  100 

per  cent,    per  cent,    per  cent,    grams. 

Lettuce 1.2  0.3  2.2  17 

Cucumber.s 0.8  0.2  2.3  15 

Spinach 2.1  0.3  2.3  21 

Asparapciis 1.8  0.2  2.4  19 

Rhubarb 0.6  0.7  2.5  19 

Endive 1.0  0.0  2.6  15 

Vegetable  marrow 0.1  0.2  2.6  13 

Sorrel ..  3.0  12 

Sauerkraut 1.7  0.5  3.0  24 

Beet  greens,  cooked 2.2  3.4  3.2  54 

Celery 1.1  0.1  3.3  18 

Tomatoes 0.9  0.4  3.3  21 

Brussels  sprouts 1.5  0.1  3.4  21 

Watercress 0.7  0.5  3.7  23 

Sea-kale 1.4  0.0  3.8  21 

Okra 1.6  0.2  4.0  25 

Cauliflower 1.8  0.5  4.3  30 

Eggplant ...  1.2  0.3  4.3  25 

Cabbage       .      .      .      (range    3.0-  6.5)  1.6  0.3  4.7  29 

Radishes      .      .      .      (range    2.7-7.5)  1.3  0.1  5.0  27 

Leeks 1.0  0.4  6.0  32 

Mushroom.si       .      .      (range    2.0-18.0)  3.5  0.4  6.0  43 

Pumpkins     .      .      .      (range    3.0-14.0)  1.0  0.1  6.0  30 

String  beans      .      .      (range    3.9-10.0)  2.3  0.3  6.0  37 

Turnips        .      .      .      (range    2.3-18.0)  1.3  0.2  6.0  32 

Celery  root 2.0  0.4  6.3  26 

Kohl-rabi     .       .      .      (range    3.5-14.0)  2.0  0.1  7.0  38 

Oyster  plant 1.2  0.1  7.0  35 

Rutabagas   .      .      .      (range    3.0-12.0)  1.3  0.2  7.0  36 

Truffles 9.1  0.5  7.0  71 

Squash    ....      (range    3.0-15.0)  1.4  0.5  8.0  43 

Beets       ....      (range    6.0-10.0)  1.6  0.1  9.0  44 

Carrots  ....      (range    5.9-11.5)  1.1  0.4  9.0  45 

Onions    ....      (range    4.0-14.0)  1.6  0.3  9.0  46 

Parsnips        .       .      .      (range    6,0-14.0)  1.6  0.5  11.0  56 

Chicory        ..  15.0  62 

•  The  protein  and  carbohydrate  in  these  are  to  a  considerable  extent 
unassimilable,  and  patients  often  eat  these  with  impunity,  as  I  have  found 
since  my  attention  was  called  to  this  fact  by  Professor  Wardall. 


DIET  TABLES 


.153 


Vegetables:  Fresh — Continuefj. 


Peas        .... 
Artichokes* 
Yams^     .... 
Corn       .... 
Potatoes 
Lima  beans 
Sweet  potatoes 
Soy  beans'   . 

Beans,  haricot-verts 

Asparagus    . 

Brussels  sprouts 

Okra       .      .      . 

Tomatoes     . 

String  beans 

Macedoine,     mixed 
vegetables 

Artichokes   . 

Pumpkins 

Peas 

Squash    . 

Beans,      haricot- 
flageolets 

Lima  beans 

Baked  beans 

Red  kidney  beans 

Corn 

Succotash     . 


Protein, 
per  cent. 

7.0 
2.0 


3.1 
2.2 
7.1 
1.8 
20.0 


(range  13.0-27.0) 

(range  16.5-44.5) 
(range  19.3-39.0) 

Vegetables:  Canned. 

1.1 

(range    1.6-3.3)  1.5 

.      .....  1.5 

.......  0.7 

(range    1.0-  4.5)  1.2 

(range    1.5-4.5)  1.1 


(range 
(range 
(range 
(range 
(range 


1.9-  5.0) 
3.2-  6.1) 
3.6-  7.3) 
4.3-17.2) 
3.6-12.8) 


1.4 
0.8 
0.8 
3.6 
0.9 


(range  9.8-12.4)  4.6 
(range  9.6-16.5)  4.0 
6.9 


7.0 

(range  11.7-25.1)       2.8 
(range  13.9-21.3)       3.6 


Vegetables: 


Beans 
Cow  peas 
Peas 
Lentils    . 
Lima  beans 


Dried. 
22.5 
21.4 
24.6 


25.7 
18.1 


Fat, 
per  cent. 

0.5 
0.2 

1.1 
1.1 
0.7 
0.1 
4.3 

0.1 
0.1 
0.1 
0.1 
0.2 
0.1 

0.0 
0.0 
0.2 
0.2 
0.5 

0.1 
0.3 
2.5 
0.2 
1.2 
1.0 


1.8 
1.4 
1.0 
1.0 
1.5 


Berries  and  Fruits:  Fresh. 


Strawberries 1.0 

Grape  fruit 

Alligator  pear 

Lemons 1.0 

Watermelons     .      . 0.3 

Blackberries 1.3 

Cranberries .       0.4 

Peaches 0.5 

Muskmelons 0.7 

Raspberries .  '    .        1.7 


0.6 


0.9 
0.1 
1.0 
0.6 
0.2 
0.3 
1.0 


Carbo- 
hydrates, 
per  cent. 

15.0 
16.0 
16.0 
19.0 
20.0 
22.0 
26.0 
28.0 


2.0 
2.3 
2.9 
2.9 
3.0 
3.3 

3.9 

4.4 

6.0 

10.0 

10.0 

11.0 
13.0 
17.0 
17.0 
18.0 
18.0 


55.0 
55.0 
58.0 
59.0 
66.0 


5.0 
6.0 
7.0 
7.0 
7.0 
8.0 
8.0 
9.0 
10.0 
10.0 


Caloric 

value 
per  100 
grams. 

95 

78 

66 

101 

•  101 

126 

120 


14 
26 
19 
16 
19 
19 

22 
21 
30 

58 
49 

65 
72 
121 
100 
97 
98 


334 
326 

348 
357 
359 


30 
25 
29 
31 
32 
56 
41 
41 
47 
45 


1  French  artichokes.  According  to  Konig,  canned  artichokes  contain 
92.46  per  cent,  water,  0.79  per  cent,  protein,  0.02  per  cent,  fat,  4.43  per  cent, 
carbohydrates. 

2  Sorrel,  chickory  and  yams  also  contain  protein  and  fat, 
'  The  carbohydrate  is  non-assimilable. 


154 


DIET  TABLES 


Berries  and  Fruits:  Frksh — Continued. 

Caloric 

Carbo-  value 

Protein,         Fat,  hydratee,    per  100 

per  cent,    per  cent,  per  cent,  grams. 

Whortleberries 0.7           3.0  10.0  72 

Apples 0.4           0.5  11.0'  71 

Pears 0.4           O.G  11.0  72 

Apricots 1.1            ?  12.1)  54 

Gooseberries 0.4            .  .  12.0  51 

Mulberries 0.3  12.0  48 

Pineapples 0.4           0.3  12.0  54 

Currants 0.4            ..  13.0  55 

Oranges 0.8           0.2  13.0  63 

Mangoes 13.0  53 

Grapes 1.3           l.G  15.0  75 

Nectarines 0.6            ?  15.0  64 

Cherries 0.8           0.8  17.0  80 

Figs 1.5            ..  17.0  76 

Huckleberries 0.6           0.6  17.0  78 

Plums 1.0  17.0  74 

Pomegranates 1.5           1.6  17.0  91 

Prunes 0.8            ?  19.0  81 

Bananas 1.5           0.7  20.0  95 

Bananas,  red 1.2           0.7  17.5  81 

Persimmons 0.8           0.7  32.0  141 

Dates 1.9         Trace  54.0  229 

Oranges.- 

Florida,  average  of  seven  analyses  (soluble  portion)    .      .  8.0  33 

California,  average  of  eight  analj'ses  (soluble  portion)      .  8.3  34 

Gr-a-pe  Fruit." 

Porto  Rico,  average  of  two  analyses  (soluble  portion)       .  8.2  34 

California,  average  of  four  analyses  (.soluble  portion)        .  6.9  28 

Florida,  average  of  four  analyses  (soluVjle  portion)       .      .  6.6  27 

Fruits:  Canned. 

Peaches 0.7           0.1  11.0  49 

Blueberries 0.6           0.6  13.0  61 

Pineapples   .      .      .      (range    6.0-25.0)       0.4           0.7  15.0  70 

Apricots 0.9            ?  17.0  73 

Pears 0.3           0.3  18.0  78 

Cherries 1.1           0.1  21.0  92 

Crab  apples 0.3            2.4  54.0  245 

Blackberries 0.8           2.1  56.0  252 

Jams,  jellies,  preserves  and  marmalade  contain  47  per  cent,  or  more 
carbohydrate.  There  is  a  wide  variation  in  the  sugar  content  of  canned 
fruits.  Pie  peaches  are  packed  in  water  while  other  grades  may  be  found 
in  30,  40  or  even  50  per  cent,  syrup. 

1  Variation  in  carbohydrate  9.0  to  21.0  per  cent. 

2  If  carbohydrate  in  peeled  oranges  is  reckoned  at  10  per  cent.,  com- 
paratively little  error  \\dll  result.  Analyses  of  oranges  and  grape  fruit 
made  for  me  by  E.  M.  Frankel,  Ph.D. 


DIET  TABLES 


155 


Fruits:  Dried. 
Contain  63  per  cent,  or  more  of  carbohydrate. 

Caloric 

Carbo-  value 

Protein,         Fat,       hydrates,  per  100 

per  cent,    per  cent,    per  cent,  grams. 

Pickles  and  Condiments. 

Distilled  vinegar 0                0                0  .0 

Cider  vinegar' 0                0              0.2.5  1 

Cucumber  pickles 0.5           0.3           2.7  16 

Capers 3.2           0.5           5.0  41 

Prepared  mustard 4.7           4.1           5.0  78 

Prepared     mustard 

plus  cereal      .      .      (range    4.0-15.0)       3.5            1.9           7.0  61 

Ketchup       .      .      .      (range    3.0-26.0)        1.8           0.2          10.0  50 

Spiced  salad  vinegar ..            10.0  41 

Horseradish 1.4           0.2          11.0  .53 

Chili  sauce  .      .      .      (range  14.0 -28.0)        ..               ..            20.0  82 

Spiced  pickles 0.4           0.1         21.0  89 

Olives,  green'^ 2.1         12.9           1.8  137 

Olives,  ripe 2.0         21.0           4.0  220 

Peppers  (paprica),  green,  dried    .      .      .      15.5           8.5         63.0  400 


Nuts. 

Filberts 15.6 

Hickory  nuts 15.4 

Peanuts 25.8 

Pecans ■.      .  11.0 

Pine  nuts;  pignolias 33.9 

Pistachios,  first  quality,  shelled   .      .      .  22 . 3 

Walnuts,  California 18.4 

Walnuts,  California,  black      .      .      .      .  27.6 

Walnuts,  California,  soft  shell      .      .      .  16.6 

Almonds       .      .      . 21.0 

Brazil 17.0 

Butternuts 27.9 

Chestnuts,  fresh 6.2 

Chestnuts,  dried 10.7 

Cocoanuts 5.7 


65.3 

13.0 

724 

67.4 

11.4 

736 

38.6 

24.4 

563 

71.2 

13.3 

760 

49.4 

6.9 

626 

54.0 

16.3 

659 

64.4 

13.0 

726 

56.3 

11.7 

683 

63.4 

16.1 

723 

54.9 

17.3 

667 

66.8 

7.0 

364 

61.2 

3.5 

95 

5.4 

42.1 

248 

7.0 

71.5 

392 

50.6 

27.9 

607 

1  Professor  Street  writes  (November  27,  1916):  "In  our  last  examination 
of  27  brands  we  found  the  reducing  sugars  to  range  from  0.27  to  1.52  per 
cent." 

^  Univ.  Calif.  College  Agriculture,  1916.     Personal  communication.         ^ 


156 


DIET  TABLES 


Dairy  Products,  etc. 

Caloric 

Carbo-  value 

Protein,         Fat,  hydrates,  per  100 

per  cent,    per  cent,  per  cent,  grams. 

MUk,  whole 3.3           4.0  5.0  72 

Milk,  condensed,  sweetened   .      .                    8.8           8.3  54.1  334 
Milk,  condensed,  unsweetened,  "evapo- 
rated cream"       9.6           9.3  11.2  172 

MUk,  skimmed 3.4           0.3  5.1  37 

Cream,  approximately  20  per  cent,  fat  .        2.3'        18.5  4.5  194 

Cream,  40  per  cent,  fat 1.5'        40.0  3.0  378 

Buttermilk 3.0           0.5  4.8  36 

Whev 1.0           0.3  5.0  27 

Kepiiir 3.1           2.0  1.6  38 

Koumiss 2.8           2.0  5.4  53 

Cheese,  cottage 17.6           2.4  1.4  98 


Milk  Powders. 

Protein.  Fat.  CHO. 

1909      TrumUk 25.7  27.3  37.2 

1913       Klim 3C.3  2.2  50.5 

1918  Mammala 25.8  14.5  49.9 

1919  Krj'stalak 35.4  3.2  48.2 

1918      Lactora 32.5  2.6  48.5 


Calories 
per  100 
grams. 

497 
367 
433 
363 
347 


Cheese. 


1913  Casino  Camembert 

1913  Maclaren's  Nippy  Cheese 

1913  Sap  Sago  Swiss  Spalty 

1913  Isigny  Type  Cheese     . 

1913  Le  DeUcieux  Camembert 

1913  ShefTord  Snappy  Cheese  . 

1913  Star  Brand  Cream  Cheese 

1913  International  Welsh  Rarebit 

1913  Liederkranz  Cheese 

1913  Maclaren's  De\Tled  Cheese 

1913  Cow  Brand  Cheese      .      . 


Protein. 
19.7 
26.9 
52.8 
21.9 
18.4 
26.3 
12.7 
25.0 
16.3 
25.6 
19.1 


Protein, 
per  cent. 

Cheese,  American,  pale 28.8 

"       American,  red 29.6 

Camembert 21.0 

"       Cottage 20.9 

"       Dutch 37.1 

"       Full  cream 25.9 

"       Limburger 23.0 

Neufchatel 18.7 

"       Pineapple 29.9 

Roquefort 22.6 

"       Skimmed  milk 31.5 

"       Swiss 27.6 


Fat. 
25.7 
38.6 
2.8 
9.9 
26.5 
39.4 
47.3 
35.3 
26.4 
33.8 
31.9 


Fat, 
per  cent. 

35.9 
38.3 
21.7 
1.0 
17.7 
33,7 
29.4 
27.4 
38.9 
29.5 
16.4 
34.9 


Undetermined 
(chiefly  ash). 

5.8 
5.2 

.1 

.3 

.4 


12. 
5. 
4. 


3.4 
2.0 
5.1 


Caloric 
Carbo-  value 
hydrates,  per  100 
per  cent,    grams. 


0.3 
? 

V 

4.3 
? 

2.4 
0.4 
1.5 
2.6 
1.8 
2.2 
1.3 


452 
476 
290 
112 
316 
429 
369 
337 
494 
374 
290 
442 


» Estimated.— E.  P.  J. 


DIET  TABLES 


157 


Oils  and  Fats. 

Protein,  Fat, 

per  cent,  per  cent. 

Butter 1.0  85.0 

Oleomargarine 0.8  92.4 

Nut  margarine 0.9  87.1 

Lard,  tallow,  cod-liver  oil,  olive  oil,  pea- 
nut oil  and  other  edible  fats  as  Wesson 

Oil,  Mazola,  Vegetable,  Kuxit,  etc.   .  .  .         85  to  100 

Meat. 

Beef,  cooked: 

Roast 22.3  28.6 

Round  steak,  fat  removed        ...      .  27 . 6  7.7 

Calf's  foot  jeUy 4.3  0.0 

Beef,  canned : 

Dried  beef 39.2  5.4 

Beef,  corned  and  pickled: 

Corned  beef,  all  analyses    .      .      .      .  15.6  26.2 

Mutton,  cooked: 

Mutton,  leg  roast     .      .                  .      .  25.0  22.6 

Pork,  pickled,  salted  and  smoked: 

Ham,  smoked,  lean 19.8  20.8 

Bacon,  smoked,  all  analyses     .      .      .  10.5  64.8 

Sausage,  A: 

Bologna  sausage       (range    0.2-3.1)  18.7  17.6 
Frankfort       .      .      (range    0.0-6.6)  19.6  18.6 
Pork      (range  carbohydrate  0.0-8.6)  13.0  44 . 2 
Deerfoot  Farm,  cooked,  analysis  fur- 
nished by  the  manufacturers      .      .  19.93  54.21 

Poultry  and  game,  fresh: 

Chicken,  broilers 21.5  2.5 

Fowls 19.3  16.3 

Goose,  young 16.3  36.2 

Turkey 21.1  22.9 

Liver: 

Beef 21.0  4.5 

Chicken,  as  purchased 22.4  4.2 

Goose,  as  purchased 16.6  15.9 

Mutton,  as  purchased 23.1  9.0 

Pork,  as  purchased 21.3  4.5 

Turkey,  as  purchased 22.9  5.2 

Veal,  as  purchased 19.0  5.3 

Tripe,  canned 16.8  8.5 

Fish:  Fresh. 

Cod  sections 16.7  0.3 

Flounder,  whole 14.2  0.6 

Haddock,  entrails  removed     .      .      .      .  17.2  0.3 

Halibut,  steaks  or  sections     .      .      .      .  18.6  5.2 

Mackerel,  whole 18.7  7.1 

Salmon,  whole 22.0  12.8 

Shad,  whole 18.8  9.5 

Trout  (brook),  whole        19.2  2.1 


Carbo- 
hydrates, 
per  cent. 


17.0 


0.6 
1.1 
1.1 


Caloric 

value 

per  100 

grains. 

793 

835 

788 


800-900 


356 
185 

87 

211 

307 

312 

274 
645 

243 

258 
468 


0.34       587 

111 
230 
403 
299 


1.7 
2.4 
3.7 
5.0 
1.4 
0.6 


133 
141 
231 
199 
135 
144 
127 
147 


72 

64 
74 
124 
142 
209 
165 


158 


DIET  TABLES 


Fish:  Preserved  and  Canned. 


Carbo- 
hydrates, 
per  cent,    per  cent,    per  cent. 


Protein,        Fat, 


Cod,  salt,  "boneless" 27.3 

Herring,  smoked 36.9 

Sardines,  canned 23.0 

Shad  roe 20.9 

Sturgeon  cav'iare 30.0 

Shell-fish. 

Clams,  long,  in  shell 8.6 

Crabs,  hardshell,  whole 16. 6 

Lobster,  whole 16.4 

Mussels,  in  shell 8.7 

Oysters,  in  shell 6.2 

Scallops,  as  purchased 14.8 

Terrapin 21.2 

Turtle,  green,  whole 19.8 


0.3 
15.8 
19.7 

3.8 
19.7 


1.0 
2.0 
1.8 
1.1 
1.2 
0.1 
3.5 
0.5 


2.0 
1.2 
0.4 
4.1 
3.7 
3.4 


Caloric 

value 

per  100 

grams. 

108 
298 
277 
121 
198 


53 
91 
86 
63 
52 
76 
120 
86 


Gelatin. 


Gelatini 


91.4 


0.1 


375 


Eggs. 


Eggs,  edible  portion  :- 
Hens',  uncooked 
Hens',  boUed 
Hens',  boiled  whites 


13.4 
13.2 
12.3 


Hens',  boiled  yolks 15.7 


10.5 

12.0 

0.2 

33.3 


158 

168 

55 

376 


Beef 

Bean 

Chicken 

Clam  chowder 

Meat  stew 4.6 


Soups:  Home-made 

.      .      .      .       4.4 

.      .      .      .       3.2 

.      .      .      .      10.5 

.      .      .      .        1.8 


0.4 
1.4 
0.8 
0.8 
4.3 


1.1 
9.4 
2.4 
6.7 
5.5 


26 
65 
61 
43 

81 


Soups:  Canned. 

Bouillon 2.2 

Chicken  gumbo 3.8 

Chicken  soup 3.6 

Consomme 2.5 

Julienne 2.7 

Mock  turtle       ........  5.2 

Mulhgatawny 3.7 

Oxtail 4.0 

Pea  soup 3.6 

Tomato  soup 1.8 

Vegetable 2.9 


0.1 
0.9 
0.1 


0.9 
0.1 
1.3 
0.7 
1.1 


0.2 
4.7 
1.5 


7.6 
5.6 
0.5 


11 
43 
22 
12 
13 
41 
40 
46 
52 
41 
14 


1  Many  of  the  brands  of  commercial  gelatin  are  said  to  contain  from  83 
to  87  per  cent,  gelatin,  11  to  14  per  cent,  moisture  and  1  to  2  per  cent,  of 
ash.— E.  P.  J. 

2  One  egg  contains  approximately  protein  6  grams  and  fat  6  grams,  of 
which  one-half  the  protein  and  all  the  fat  are  in  the  yolk. — E.  P.  J. 


DIET  TABLES 


159 


Canned  Bouillons. 

Protein. 

Acker,  Merrall  and  Condit 2.0 

Schimmell's 0.8 

Campbell's 1.3 

Curtice  Bros.  Blue  Label         2.1 

Franco-American 1.6 

Mohican 0.5 


Fat. 

Salt. 

0.1 

1.4 

0.1 

2.3 

0.1 

1.8 

0.2 

0.9 

0.1 

0.9 

0.1 

2.5 

Bouillon  Cubes. 

Sodium  chloride, 
per  cent. 

Armour's  Beef  Extract  and  Vegetable  Tablets 21.00 

Mason's  Beef  Tea  Lozenges 2 .  24 

Anker's  Bouillon  Capsules 30.00 

Steero  BouUlon  Cubes 59.48 

Knerr's  Consomme 61.46 

O.  X.  O.  Bouillon  Cubes 62.70 

Vegex  Cubes      .      .' 57 .  02 


Flour,  Meals,  Bread,  Pastry,  etc. 

Caloric 

Carbo-  value 

Protein,  Fat,  hydrate,  per  100 

per  cent,  per  cent,  per  cent,  grams. 

Flours,    meals,    etc.: 

Barley  meal  and  flour 10.5  2.2  72.8  .361 

Buckwheat  flour       ......        6.4  1.2  77.9  356 

Cornmeal,  unbolted 8.4  4.7  74.0  .381 

Hominy 8.3  0.6  79.0  363 

Oatmeal 16.1  7.2  67.5  409 

Rolled  oats 16.7.  7.3  66.2  407 

Rice 8.0  0.3  79.0  359 

Rice,  boiled 2.8  0.1  24.4  112 

Rye  flour 6.8  0.9  78.7  359 

Wheat  flour,  California  fine      ...       7.9  1.4  76.4  358 
Wheat  flour,  entire  wheat  .      .      .      .      13.8  1.9  71.9  369 
Wheat  flour,  patent  roller  process,  high 
grade  (average  of  all  analyses  of  high 
medium  grades  and  grade  not  indi- 
cated)          11.4  1.0  75.1  363 

Wheat  preparations: 

"Shredded  Wheat  Biscuit"!      ...        8.3  0.6         76.0  351 

"Wheatena" 11.3  2.8         76.0  384 

"Cream  of  Wheat" 11.5  0.9         75.0  353 

Cracked  wheat 11.1  1.7         74.0  365 

"Wheatlet" 12.8  1.6         74.0  371 

"Quaker  Wheat  Berries"     ....      13.8  1.9         72.0  370 

Macaroni 13.4  0.9         74.1  366 

Macaroni,  cooked 3.0  1.5         15.8  91 

Soy  bean  meal 42.5  19.9         34. 0=  499 

Pea  flour 25.7  1.8  57.0  354 

Acorn  meal 7.3  4.9         64.0  338 

1  Weight  of  1  biscuit  30  grams,  and  it  contains,  approximately,  carbohy- 
drate 23  grams  and  protein  3  grams. 

*  The  assimilable  carbohydrate  in  soy  beans  is  3  per  cent,  or  less. 


160 


DIET  TABLES 


Flour,  Meals,  Bread,  Pastry,  etc. — Continued. 

Caloric 

Carbo-  value 

Protein,        Fat,  hydrate,  per  100 

per  cent,    per  cent,  per  cent.  gramB. 

Graham  flour 13.3           2.2  70.0  362 

Pop  corn,  popped 10.7           5.0  77.0  586 

Cassava  meal 1.3           1.2  81.0  348 

Potato  starch 0.9           0.1  81.0  337 

Sago  starch 2.2           0.0  81.0  341 

Tapioca  (arrow-root) 0.1           0.1  84. 0  346 

Banana  flour 3.9           1.0  85.0  .375 

Cornstarch 1.2           0.0  85.0  353 

Rye 10.2           1.7  72.0  .353 

Buckwheat 10.1           2.5  61.0  315 

" Ralston  Health  Food " 11.9           1.7  72.0  360 

"Force" 10.6           1.1  74.0  358 

" Pettijohn's  Breakfast  Food "     ...       9.1           2.0  74.0  359 

" Malt  Breakfast  Food " 13.8           1.5  75.0  378 

"Triscuit" 11.0           1.4  75.0  365 

"Grape  Nuts" 11.5           0.6  75.0  360 

Farina 11.0           1.4  75.0  367 

"Mapl-Flake" 11.0           1.4  76.0  369 

Hominy 7.6           0.2  78.0  353 

Puffed  rice 6.7           0.4  80.0  359 

Toasted  corn  flakes ..  81.0  332 

Caloric 

Carbo-  value 

Protein,       Fat,       hydrate^    Starch,  per  100 

per  cent,  per  cent,  per  cent,  per  cent,  grams. 

11913    Glidine :  Menley  &  James, 

New  York  ....  91.4  0.8  1.0  0  377 
1909    Plasmon:    Plasmon    Co., 

London 78.7          2.7          0.0  ..  339 

1915    Cotton-seed  flour:  Allison, 

Schulenburg    Oil     Mill, 

Schulenburg,  Texas       .      50.4        11.2          ..  1.1  348 


Wheat  Bran. 


Protein, 
per  cent. 

1914  Ballard's  Obelisk  Sanitary  Edible 

Bran 17.3 

1917  Gulp's  Capitol  Health  Bran  .      .  13.4 

1914  Health  Food  Co. 's  Wheat  Bran  .  14.3 

1914  Jireh  Wheat  Bran        ....  16.8 

1914  .Johnson's  Educator  Wheat  Bran  15.4 

1914  Kellogg's  Sterilized  Wheat  Bran  16.:-. 


Carbo- 

Fat,       hydrate, 

per  cent,  per  cent. 


5.4 
4.3 
4.1 

4.8 
4.7 
5.2 


55.7 
57.6 
56.2 
56.7 
54.4 
54.4 


'  Analysis  of  preparation  manufactured  at  this  date. 

2  For  interpretation  of  "carbohydrate"  see  footnote  page  151. 


DIET  TABLES 


lf)l 


Wheat  Bran — Continued. 

Caloric 

Carbo-  value 

Protein,  Fat,  hydrate,  per  100 

per  cent,  per  cent,  per  cent,     grams. 

Bread:' 

Bread,  brown 5.4  1.8  47.1  2.31 

Bread,  corn  (Johnnycake)  ....        7.9  4.7  46.3  265 

Bread,  rye 9.0  0.6  53.2  260 

Graham  bread 8.9  1.8  52.1  2'66 

Rolls,  French 8.5  2.5  55.7  286 

Rolls,  all  analyses 8.9  4.1  56.7  307 

Toasted  bread 11.5  1.6  61.2  312 

White  bread,  home-made    .      .      .      .        9.1  1.6  53 . 3  270 

White  bread,  miscellaneous       ...        9.3  1.2  52.7  266 

Whole  wheat  bread 9.7  0.9  49.0  249 

Whole  rye  bread 11.9  0.6  35.0  198 

Peanut  bread 33.6  12.8  20.0  339 

Acorn  bread ••  27.0  111 

Cassava  bread ..  27.0  111 

Alfalfa  bread       . 10.6  1.3  64.0  318 

Crackers: 

Boston  (split)  crackers         .      .      .      .      11.0  8.5  71.1  415 

Uneeda  Biscuit^ 10.1  8.8  70.0  399 

Graham  crackers 10.0  9.4  73.8  430 

PUot  bread    ........      11.1  5.0  74.2  396 

Saltines 10.6  12.7  68.5  441 

Zwieback 9.8  9.9  73.5  433 

Peanut  zwieback 23.2  8.0  28.0  284 

Doughnuts.      .      .      (range  45.0-63.0)        6.7  21.0  52.0  4.36 

Cake    (exceut   fruit 

cake)          .      .      .      (range  53.0-78.0)        6.3  9.0  63.0  368 

Jumbles        .      .      .      (range  52.0-71 .0)       7.4  13.5  63.0  418 

Fruitcake 5.0  10.9  64.0  384 

Macaroons.      .      .      (range  57 . 0-70 . 0)        6.5  15.2  64.0  430 

Pie: 

Apple        3.1  9.8  42.8  279 

Custard 4.2  6.3  26.1  183 

Squash 4.4  8.4  21.7  185 

Mince       .      .      .      (range  30.0-44.0)       5.8  12.3  38.0  194 

Pastes. 

Noodles 13.3  0.8  72.0  357 

VermicelH     .      .      .      .      .      .      .      .      .      10.9  2.0  72.0  358 

Spaghetti 12.1  0.4  74.0  353 

1  Recent  analyses  by  Street  have  shown  that  the  method  generally  used 
for  determining  fat  in  bread  gives  too  low  results.     In  fourteen  samples  the 

average  fat  by  the  usual  method  was  0 .  59  per  cent,  while  by  an  improved 
method  it  was  1.95  per  cent. 

-  Analysis  from  Conn.  Exp.  Sta.  Report,  1914,  p.  230.  One  biscuit  weighs 
7  grams  and  contains  about  5  grams  carbohj^drate,  0.7  gram  protein  and 
0.5  gram  fat. 

u 


162 


DIET  TABLES 


Carbo- 
MlSCELLANEOUS.  hydrate, 

per  cent. 

Plain  chocolate 25.0 

Cocoa  nibs,  roasted 28.0 

Baking  powder  (range  0-51 .5)     32.0 

Cocoa 38.0 

Milk  chocolate 51.0 

Milk  cocoa 52.0 

Custard  powders 59.0 

Sweet  chocolate 67.0 

•KT  T^  Carbo- 

NON-ALCOHOLIC    BEVERAGES.  hydrate, 

per  cent. 

Tea  (0.5  oz.  to  1  pt.  water) 0.6 

Coffee  (1  oz.  to  1  pt.  water)         0.7 

Cocoa  (0.5  oz.  to  1  pt.  water) 1.1 

Cider (range  0-13.5)  4.5 

Cocoa  (0.5  oz.  to  1  pt.  milk) 6.0 

Cream  or  lemon  soda 7.0 

Sarsaparilla 7.0 

Birch  l)eer 8.0 

Ginger  ale 8.0 

Root  beer 9.0 

Total 
Near  Beers.  reducing 

sugars. 

Anzac 5.4 

Bevo 5.8 

Wesco 4.2 

Pablo 4.8 


Protein,  Fat, 

per  cent,  per  cent. 

Chocolate' 12.9  48.7 

Cocoai 21.6  28.9 

Cereal  coffee  infusion  (1  part  boiled  in 

20  parts  water) 0.2 


Caloric 

Carbo- 

value 

hydrate, 

per  100 

per  cent. 

grams. 

30.3 

629 

.37.7 

510 

1.4 


Coffee  Substitutes.^ 


Carbo- 

Protein, 

Fat, 

hydrate, 

Starch, 

Caffein, 

per  cent. 

per  cent. 

per  cent. 

per  cent. 

per  cent 

Drinket 

5.69 

0.03 

81.85 

None 

Old  Grist  Mill  .      . 

.       15.13 

3.87 

58.91 

30.38 

0.17 

Jaffee      .... 

.       11.00 

1.66 

62.72 

16.40 

None 

Postum  Cereal 

.       12.38 

3.30 

59.71 

19.20 

None 

Calumet  Cereal 

.       13.06 

4.44 

63.06 

37.97 

0.08 

Barley  Coffee    . 

.       10.81 

2.73 

72.12 

42.80 

None 

'  Analyses  of  food  and  not  of  beverages  or  infusion. 
-  Analyses  by  .John  Phillips  Street. 


DIET  TABLES 


163 


So-called  Diabetic  Pkepara- 

TIONS.l 


Flours  and  Meals. 

1910  Acme  Mills  Co.,  Portland,  Ore.   . 
Herman  Barker,  Somerville,  Mass. : 

1912  Barker's  Gluten  Food,  "A" 

1913  Barker's  Gluten  Food,  "B" 

1913  Barker's  Gluten  Food,  "C" 

1914  Battle     Creek     Sanitarium     Co., 

Battle  Creek,   Mich.,   80  per 
cent.  Gluten  Meal 
Callard,  Stewart  &  Watt,  London: 

1909  Casoid  Flour 

Cereo  Co.,  Tappan,  N.  Y. : 
1913         Soy  Bean  Gruel  Flour     .      .      . 
Christian's    Natural    Food    Co., 
Kenilworth,  N.  J.: 
Christian's  Imported  Protoid  Nuts 
Farwell    &    Rhines,    Watertown, 
N.  Y.:   .      .      .      . 
1913         Gluten  Flour  .      .      . 
1913         Gluten  Flour  .      .      . 
1913         Cresco  Flour  .      .      . 
1913         Special  Dietetic  Food 
1913      Golden  Rod  Milling  Co., Portland 

Ore.,  Acme  Special  Flour 

1913      O.  B.  Gilman,  Boston,  Mass.: 

Gluten  Flour 

1913  Health  Food  Co.,  New  York: 

Almond  Meal        .... 

1914  Almond  Meal        .... 

1911  C  B  X  Cold  Blast  Flour,  25  per 

cent,  protein     .... 
1913         Pronireu  (Griddle-cake  Flour) 

1913  Glutosac  Gluten  Flour    .      . 

1914  Gluten  Flour  No.  1    .      .      . 
1914         Pure  Washed  Gluten       .      . 

1913  Pure  Washed  Gluten  Flour 

1914  Protosac  Gluten  Flour    . 
1914         Protosoy  Soy  Flour  .      .      . 
1906      Jireh  Diabetic  Food  Co.,  New  York: 
1906         Diabetic  Flour 


*:      73      c 


o 

a 
.  "^ 

^  9. 

a  0- 

5S2 

_o   OJO 

o 

9.4 

1.9 

77  A 

71.4 

.'364 

86.9 

0.5 

4.6 

trace 

370 

85.1 

0.6 

7.2 

3.7 

375 

84.1 

0.6 

8.6 

3.4 

377 

84.0 

' 

5.8 

368 

82,5 

1.6 

3.1 

0 

357 

43.1 

21.4 

24.9 

trace 

465 

37.6     48.2       5.7    trace     607 


.      43.1 

1.2 

46.6 

38.1 

370 

.      46.3 

1.1 

42.9 

32.8 

367 

.       18.1 

1.0 

67.4 

57.2 

351 

.       27.5 

] 

2.8 

56.6 

40.0 

362 

I, 

.       15.8 

1.4 

71.4 

57.9 

361 

.      47.3 

2.0 

40.4 

31.4 

369 

.       50.3 

14.8 

17.9 

trace 

406 

.       49.1 

21.8 

15.9 

0 

457 

r 

.       10.1 

0.9 

79.6 

68.9 

367 

.       37.3 

1.2 

47.3 

37.7 

349 

.       39.9 

2.3 

47.5 

36.9 

370 

75.7 

0.9 

12.8 

7.1 

362 

85.6 

1.0 

5.4 

2.8 

373 

80.3 

1.6 

11.1 

7.0 

380 

45.9 

2.0 

42.3 

31.5 

370 

.       42.9 

19.2 

26.0 

1.9 

448 

14.3       2.2     71.9     66.62    365 


-^  1  See  footnote  page  151  for  method  employed  in  calculating  carbohydrate 
at  Conn.  Agricultural  Experiment  Station.  By  this  method  of  calculation 
the  carbohydrate  in  various  preparations,  such  as  those  made  from  casein, 
may  appear  too  high  or  even  present  in  small  quantities  when  it  is  actually 
absent.  The  carbohydrate  in  preparations  made  from  soy  beans  is  unas- 
similable  and  therefore  harmless. 

2  Determined   by  the   diastase  method,   without   pre\'ious    washing  with 
water,  and  calculated  as  starch, 


164 


DIET  TABLES 


So-called  Diabetic  Phepaha- 

TIONS. 


Flours  and  Meals.— Continued. 
1913         Patent  Cotton  Seed  Flour    . 
1913         Patent  Lentils  Flour 

1913         Protein  Flour 

1913         Soja  Bean  Flour 

Johnson     Educator     Food      Co., 
Boston,  Mass.: 
1911         Educator  Standard  Gluten  Flour 

The    Kellogg    Food    Co.,    Battle 
Creek,  Mich.: 
Kellogg's 
1916  20  per  cent.  Gluten  Meal 

1916  40  per  cent.  Gluten  Flour 

1916  40  per  cent.  Gluten  Meal 

1916  Pure  Gluten  Meal        .      . 

1916  Pure  Gluten  Biscuit    . 

1916  40  per  cent.  Gluten  Biscuit 

Lister  Bros.,  New  York: 

1915  Diabetic  Flour      .... 

1916  Loeb's  Genuine  Gluten  Bread 
1916         Gluten  Luft  Bread     .      .      . 
1916         Pure  Gluten  Flour     .       .       . 
1916         Diabetic  Bread  Sticks     . 
1916         Gluten  Noodles    .... 
1916         Diabetic  Sponge  Cookies 
1916         Diabetic  Almond  Macaroons 
1916         Diabetic  Butter  Cookies 
1916  "  "  "       .      . 
1916         Diabetic  Lady  Fingers    . 
1916         Gluten  Cracker  Meal 

1916         Gluten  Almond  Zwncback     . 
1916         Gluten  Zwieback        .      .      . 

Thos.  Martindale  &  Co.,  Phila.: 
1913         Special  Gluten  Flour       .      . 

Mayflower  Mills,  Ft.  Wayne,  Ind. 
1913         Bond's  Diabetic  Flour    .      .      . 

Theo.  Metcalf  Co.,  Boston,  Mass. 
1913         Soja  Bean  Meal,   18  per  cent 

starch 

1913         Vegetable  Gluten,  8.1  per  cent, 
starch 

Pieser  Livingston  Co.,  Chicago: 

1913  Gluten  Flour 

Pure  Gluten  Food  Co.,  New  York 

1911         Gum  Gluten  Flour    .      .      .      . 

1914  Flour,  50  per  cent 

1914         Flour,  Ground 


rt  a     —  o^ 


b 


u 


CO 


U 


49.1  12.7  21.3  (i.O  396 

27.3  1.2  59.8  42.6  359 

31.4  2.0  56.7  48.5  370 
42.3  18.2  25.8  0.0  435 


40.1        1.4     50.2     40.9     374 


27.06 

0.02 

63.03 

51.24 

36.88 

1.43 

52.10 

48.04 

45.56 

1.11 

44.57 

36.50 

84.19 

0.81 

9.36 

6.77 

81.00 

0.83 

7.71 

4.02 

45.13 

0.98 

48.83 

36.98 

84.5 

3.6 

0 

35.40 

0.17 

34.99 

26.37 

44.50 

9.78 

37.29 

29.93 

47.81 

1.01 

41.69 

35.78 

46.31 

0.29 

42.19 

35.02 

45.19 

1.03 

43.69 

33.19 

44.63 

37.17 

8.66 

1.91 

34.25 

45.01 

10.46  trace 

39.31 

14.93 

37.25 

32.18 

31.38 

22.29  37.05 

30.66 

48.00 

32.79 

9.71 

2.14 

42.63 

8.92 

38.97 

31.59 

44.00 

6.10 

39.56 

33.10 

45.44 

2.39 

41.06 

35.72 

372 


40.3  1.5  49.1  41.4  371 

40.2  1.3  48.3  40.6  366 

41.0  20.0  25.0  ..  444 

80.4  1.5  9.8  5.9  374 

43.3  1.3  46.2  38.4  370 

38.3  1.6  50. S  42.4  371 

49.7  1.2  41.5  37.1  375 

41.9  0.9  48.1  42.6  36^ 


DIET  TABLES  165 

S.  H    ■ 


So-called  Diabetic  Prepara- 

a 

.  0) 

a 

a 

^  £  2 

a  S 

J3  o 

d'C  M 

tions. 

'S  u 

U 

S  ^ 

4u 

"3.30 

■H  o 

.  <u 

.p  <o 

t.  <» 

o  cjO 

on 

5» 

Sa 

a  a 

•3'-- 

P4 

^ 

o 

CO 

O 

Flours  and  Meals. — Continued. 

1914 

Self-raising  Flour       .... 

42.7 

0.8 

45.0 

39.0 

357 

1914 

Special  Flour 

Sprague,  Warner  &  Co.,  Chicago: 

90.7 

0.7 

1.7 

2.2 

-  376 

1913 

Richelieu  Gluten  Flour  . 
G.  Van  Abbott  &  Sons,  London: 

47.7 

1.2 

39.7 

31.6 

368 

1913 

Almond  Flour 

24.6 

58.6 

7.9 

0.0 

657 

1913 

Gluten  Flour 

WUson  Bros.,  Rochester,  N.  Y. : 

75.1 

0.9 

12.6 

12.4 

359 

1913 

Gluten  Flour,  f  Standard     . 

20.8 

2.1 

64.6 

54.6 

361 

1913 

Self-raising,  ^-  Standard 

n  A 

2.0 

63.5 

51.8 

342 

1913 

Waukesha  Health  Products  Co., 
Waukesha,      Wise. :      Hepco 

Flour 

42.9 

20.8 

22.31 

trace 

448 

Breakfast  Foods. 

Brusson  Jeune   Villemur,  France: 

1913 

Farine  au  Gluten       .... 

33.9 

0.6 

53.8 

48.8 

356 

1910 

Gluten  Semolina        .... 
Farwell    &    Rhines,    Watertown, 
N.  Y.: 

17.2 

0.5 

71.6 

64.9 

360 

1913 

Barley  Crystals 

11.5 

1.3 

75.2 

62.7 

359 

1913 

Cresco  Grits 

17.8 

1.4 

68.6 

54.1 

358 

1908 

Hazard's  Wheat  Protein  Break- 

fast Food 

40.1 

1.0 

49.7 

? 

368 

Health    Food    Co.,    New    York: 

1913 

Manana 

Pure  Gluten  Food  Co.,  New  York: 

37.6 

1.9 

46.8 

31.0 

355 

1914 

Gum  Gluten  Breakfast  Food 

45.4 

0.9 

46.4 

39.2 

375 

1914 

Gum  Gluten  Granules    . 

42.7 

0.7 

48.8 

41.9 

372 

1901 

Pure  Gluten  Breakfast  Cereal  . 
Waukesha  Health  Products  Co., 
Waukesha,  Wise:    Hepco  Grits^ 

Macaroni,  Noodles,  etc. 
Brusson  Jeune,  Villemur,  France : 

43.  r 

1.6 

44.4 

? 

367 

1910 

Pates  aux  Oeufs  Macaroni  . 

13.9 

0.4 

76.2 

69.2 

364 

1910 

Pates  aux  Oeufs  Nouillettes 

14.4 

0.5 

75.7 

68.9 

365 

1913 

Petites  Pates  au  Gluten        .      . 

18.6 

1.0 

70.4 

61.2 

365 

1910 

Vermicelle  au  Gluten 

18.4 

0.4 

72.4 

65.8 

367 

Jireh   Diabetic    Food    Co.,    New 
York: 
1913         Macaroni 16.9       0.9     71.4     58.8     361 

1  Chiefly  derived  from  Soy  bean  and  therefore  non-assimilable,  and  for 
patients  can  be  considered  carbohydrate-free. 

2  Said  to  be  identical  with  Hepco  Dodgers. 


IGO 


DIET   TABLES 


1913 

1914 
1913 
1913 
1914 


1914 
1914 


1914 


1913 
1914 


1915 


So-called  Diabetic-  Phkpaka- 

TIDNS. 


Macaroni,  Noodles,  etc. — 

Continued. 

Loeb"s  Diabetic  Bakery,  New  York: 

Home-inade  Noodles       .      .      .      41.8 
Pure  Gluten  Food  Co.,  New  York: 

Gum  Gluten  Noodles      .      .  40.. 5 

Gust,<iv  Miiller  &  Co.,  New  York: 

Dr.  Boinua  Sugar-free  Fat-milk'       2 . 4 
D.     Whiting     &     Sons,     Boston: 
Sugar-free     Milk     (ave.     3 

analyses) 5.7 

Sugar-free  Milk 6.4 


Soft  Bre.\ds. 

Health  Food  Co. : 

Protosac  Bread 29 . 8 

Glutosac  Bread 27 . 2 

J.  Heinbockel  &  Co.,  Baltimore, 
Md.: 
Diabetic  Bread  for  Diabetes      .        8.6 

Loeb's  Diabetic  Bakery,  New  York : 
P.  &  L.  Genuine  Gluten  Bread     10.4 
P.  &  L.  Genuine  Glubetic  Bread     38.8 

Lister  Bros.,  New  York: 
Casein  Bread 36.6 


■^i 

a 

•?, 

JS  o 

^fe 

■3, 

'5^ 

S3  0. 

OS 

O 

(n 

U 

5.5     41.7     36.7     384 

1.2  49.1     41.8     369 

5.3  . .  . .  57 


7.2  trace       ..  88 

9.3  0.2       ..        110 


1.8     35.2     27.7     276 
2.1     31.1     22 . 2     252 


1.5     52.1     40.4     256 


2.6     .53.7     44.2     280 
4.1     25.7     19.2     294 


18.4 


322 


Hard  Breads  and  Bakery 

Products. 2 

Callard,  Stewart  &  Watt,  London : 

1909 

Almond  Biscuit,  plain     . 

28.3 

28.0 

36.8 

512 

1909 

Almond  Shortbreads 

19.5 

52.1 

27.0 

630 

1913 

Casoid  Biscuits,  No.  1     .      .      . 

66.8 

18.8 

5.8 

4.0 

460 

1909 

Casoid  Biscuits,  No.  2     .      .      . 

57.8 

25.5 

5.6 

0.0 

483 

1909 

Casoid  Biscuits,  No.  3    .      .      . 

54.3 

25.0 

7.8 

trace 

473 

1909 

Casoid  Dinner  Rolls        .      .       . 

78.0 

11.1 

2.1 

420 

1909 

Casoid  Lunch  Biscuit 

25.5 

44.9 

21.6 

593 

1909 

Casoid  Rusks        .      .      .      .      . 

37.0 

32.3 

20.8 

522 

1909 

Cocoanut  Biscuit — Saccharin   . 

16.6 

61.3 

16.4 

684 

1909 

Ginger  Biscuit — Saccharin  . 

17.1 

58.6 

18.1 

668 

1913 

Kalari  Batons 

43.2 

39.0 

7.4 

0 

553 

1909 

Kalari  Biscuits 

56.9 

31.4 

1.7 

517 

1909 

Prolactic  Biscuit        .... 

42.9 

27.5 

19.3 

496 

1913 

Charrasse  Biscuits  Croquettes  au 

Gluten   

34.3 

5.4 

52.3 

30.6 

395 

1913 

Biscottes  Lucullus     .... 

11.4 

5.7 

73.4 

59.2 

391 

1913 

Gluten     Exquis     Biscuits     aux 

Amandes 

18.1 

23.8 

50.6 

25.5 

489 

1  Water,  91.8  per  cent. 


2  See  footnotes,  pages  151  and  163. 


DIET  TABLES 


167 


So-called  Diabetic  Prepara- 
tions. 

Hard  Breads,  etc. — Continued. 
1913         Gluten  Fleur  de  Neige  Pain 
1913         Mignonettes  au  Gluten  . 

1913         Pain  de  Gluten 

1913         Tranches  Grillees  pour  Potage 

Health  Food  Co.,  New  York: 

1913  Alpha  Best  Diabetic  Wafer 

1914  Alpha  Best  Diabetic  Wafer 

1913  Diabetic  Biscuit 

1914  Diabetic  Biscuit 
1906  Glutona     .      . 
1906  Glutosac  Rusks 
1906  Wafers,  Plain 
1906  Salvia  Sticks  . 
1914  Gluten  Nuggets 
1914  Gluten  Butter  Wafers     . 
1914  Gluten  Rusks       .      .      . 
1914  Gluten  Wafers,  Plain      . 

Gluten  Zwieback 
1914         No.  1  Proto  Puffs      .      . 
1914         No.  2  Proto  Puffs      .      . 
1914         Protosac  Rusks    . 
1914         Protosoy  Diabetic  Wafers 
1914         Salvia  Almond  Sticks 

Heinz  Food  Co.,  Chicago: 

1913  Gluten  Biscuits 

Heudebert,  Paris: 

1914  Pain  d'Aleurone   pour   Diabet- 

iques 

1914'         Pain  de  Gluten  pour  Diabetiques 
1914         Pain    de    "Essential"    en    Bis- 

cottes 

193  4     Hoyt's  Gum  Gluten  Biscuit  Crisps 
1916     Huntley     &     Palmer,      Reading, 

England: 

Akoll  Biscuits 

Johnson     Educator     Food     Co., 

Boston: 
1913         Educator  Gluten  Bread  Sticks 

1911  Gluten  Cookies 

The    Kellogg    Food    Co.,    Battle 

Creek,  Mich.: 

1912  Avena-Gluten  Biscuit     .      . 

1913  Potato  Gluten  Biscuit     . 

1909         Pure  Gluten  Biscuit  .      .      .      . 


a 
a  o 

*J    CD 


O 


"I 

ci  p. 


05  " 

o 


35.9  12. .5  42.8  25.1  427 

40.1  5.7  43.6  27.3.  386 

40.8  5.3  43.5  27.2  385 

40.6  3.6  45.5  28.8  377 


66.1 

13.6 

11.3 

trace 

432 

67.1 

8.4 

11.7 

1.3 

391 

25.0 

9.2 

54.2 

46.5 

400 

35.9 

8.8 

46.5 

39.8 

409 

22.1 

11.8 

58.5 

54.9' 

429 

36.5 

3.8 

51.6 

42.51 

387 

29.4 

9.6 

49.9 

41.61 

404 

39.2 

20.8 

24.0 

18.71 

440 

31.7 

14.3 

45.7 

34.9 

438 

31.1 

13.9 

47.0 

38.9 

438 

39.3 

3.4 

47.0 

33.6 

376 

42.6 

1.7 

44.3 

29.6 

363 

36.4 

7.7 

46.6 

32.5 

401 

72.3 

2.8 

13.0 

9.2 

366 

58.8 

2.1 

27.0 

20.7 

362 

39.7 

3.0 

46.7 

35.9 

373 

37.1 

23.5 

29.3 

14.4 

477 

22.3 

29.9 

41.0 

28.3 

523 

12.8     18.3     57.7     21.4     447 


76.1 
80.7 


26.4 

52.7 


1.5 

0.8 


1.2 
0.5 


9.2 
6.5 


4.2 
3.4 


62.2     49.9 
38.0     31.2 


354 
356 


365 
368 


53.6     28.3       6.2     trace   494 


35.9 

7.2     45.8     37.5     392 

26.4 

16.0     49.8     37.8     449 

21.4  12.7     55.5     41.1     422 

41.5  0.5     48.0     39.5     363 
48.3       3.3     39.1        ..       379 


1  Determined  by  the  diastase  method,  without    previous   washing  with 
water,  and  calculated  as  starch. 


168 


DIET   TABLES 


So-called  Diabetic  Prkpaha- 

TIONS. 


•ga 


-3^5 


■5S. 

i^ 

■P  5 

rt  ft      -3  "- 

PL, 

(^ 

o 

OT          O 

Hard  Breads,  etc. — Continued. 

1913 

Taro-Gluteii  Biscuit 

.      31.3 

0.5 

57.7 

48.2     361 

1913 

40  per  cent.  Gluten  Biscuit 

.      37.2 

O.S 

53.2 

45 . 0     369 

1912 

SO  per  cent.  Gluten  Biscuit 

.      82. 4 

0.9 

4.4 

4.7     355 

Loeb's  Diabetic  Bakery,  New  York: 

1913 

Gluten  Luft  Bread     .      .      . 

.      27.9 

9.2 

54.2 

44.1     411 

1914 

Gluten  Luft  Bread 

.      52.4 

13.2 

26.0 

22.9     433 

1914 

Chocolate  Almond  Bars 

.      16.3 

41.0 

31.8 

5.7     561 

1914 

Diabetic  Almond  Macaroons 

.      46.5 

37.7 

8.0 

0.6     558 

1914 

Diabetic  Bread  Sticks     . 

.      50.4 

3.4 

34.5 

24.6     371 

1914 

Diabetic  Chocolates 

.      14.9 

51.4 

23.0 

6.9     614 

1914 

Diabetic  Ladjf  Fingers    . 

.      56.6 

28.3 

6.0 

1.8     505 

1914 

Diabetic  Sponge  Cookies 

.      54.7 

30.1 

5.0 

1.2     510 

Pure  Gluten  Food  Co.,  New  York: 

1913 

Gum  Gluten  Biscuit  Crisps 

.      42.9 

0.7 

48.5 

39.3     372 

1914 

No.  1  Dainty  Fluffs  .      .      . 

.      79.9 

0.5 

11.3 

10.7     370 

1914 

No.  2  Dainty  Fluffs     .      .      . 

.      66.3 

0.5 

24.9 

21.9     369 

G.  Van  Abbott  &  Sons,  London: 

1913 

Caraway  Biscuits  for  Diabetics     35.6 

37.5 

15.9 

8.6     544 

1913 

Diabetic  Rusks  for  Diabetics 

.     70.9 

0.8 

16.0 

12.6     355 

1913 

Euthenia  Biscuits 

.     35.8 

40.7 

13.2 

6.9     562 

1913 

Gluten  Biscottes  or  Rolls 

.     51.6 

2.3 

33.0 

29.8     359 

1913 

Gluten  Bread  or  Slices    . 

.      54.1 

2.2 

30.9 

27.4     361 

1913 

Gluten  Butter  Biscuits  for  Dia- 

betics      

.      44.1 

33.2 

12.7 

9.0     526 

1913 

Ginger    Biscuits    for    Diabetics     34.6 

39.4 

16.7 

10.9     560 

1913 

Midolia  Biscuits  .... 

.      17.6 

36.4 

31.6 

13.4     524 

1913 

Walnut   Biscuits   for   Diabetics     20.9 
Waukesha  Health  Products  Co., 

57.2 

12.3 

trace    648 

Waukesha,  Wis.: 

1913 

Hepco  Dodgers.         .      . 

.      41.6 

21.3 

20.7 

trace    441 

Callard,  Stewart  &  Watt,  London 

1913 

Casoid  Chocolate  Almonds 

Wines  : 

.      22.3 
Dry. 

51.8 

16.1 

trace    620 

Grams   reduc- 
ing sugars,  per 
100  c.c. 

California,  red,  Bordeaux  or  Claret 

(range 

0.04-  C 

.63) 

0.16 

"    Burgundy  . 

(range 

0.03-  0.42) 

0.15 

'             "    Zinfandel    . 

(range 

0.03-  0.35) 

0.15 

'          white,  Rhine 

(range 

0.06-  0.63) 

0.15 

'                "      Burgundy 

(range 

0.10-  0.45) 

0.23 

'               "      Sauterne 

(range 

0.07-  3.57) 

0.64 

French,  red 

(range 

0.11-  0.84) 

0.23 

" 

white           .      . 

(range 

0.65- 

1.02) 

0.84 

'  Natural  wines  contain  from  6  to  12  per  cent,  of  alcohol;  "fortified"  wines, 
such  as  port,  sherry,  madeira  and  marsala  (and  certain  champagnes),  con- 
tain from  15  to  20  per  cent. 


DIET  TABLES 


169 


Wines:  Dry. — Continued.  Grams  reduc- 
ing sugars,  per 
100  c.c. 

German, -white (range    0.09-1.96)  0.20 

Hungarian,  white (range    0.04-  0.86)  0.25 

Italian,  red (range    0.02-2.70)  0.16 

"       white (range    0.02-  2.15)  0.19 

North  Carolina (range    0.08-1.75)  0.49 

Ohio (range    0.07-  1.54)  0..31 

Portuguese,  red (range    0.01-  1.21)  0.16 

"          white (range    0.10-  1.19)  0.32 

Rhine,  red (range    0.06-0.27)  0.13 

"      white (range    0.02-  1.02)  0.18 

.Spanish,  red (range    0.19-0.54)  0.35 

"        white (range    0.27-  0.62)  0.42 

Sparkling,  French  and  German      .      .      (range    0 .  13-  1 .  95)  0 .  53 

Swiss,  red       .      .      .      .      .      .      .      .      (range    0.10-0.27)  0.13 

"     white (range    0.08-  0.38)  0.10 

Virginia (range    0.06-  1.2.3)  0.16 

Wines:  Sweet. 

California  Port (range  0.23-13.56)  4.76 

Madeira  and  Sherry      .      .  (range  0.12-17.21)  5.38 

French      (range  0.73-12.40)  5.38 

German (range  0.64-12.13)  4.60 

Madeira (range  2.48-  3.88)  2.95 

Malaga (range  12.50-25.20)  18.32 

Marsala (range  2.67-  8.24)  3.25 

Port (range  3.76-  8.17)  6.04 

Rhine (range  1.82-10.69)  6.35 

Sherry      (range  0.52-  4.80)  2.54 

Sparkling,  American (range  6.51-12.02)  8.28 

French  and  German      .      .  (range  8.00-18.50)  10.92 

Tokay,  true (range  1.86-20.50)  12.62 

"      commercial (range  2.70-40.70)  19.80 

Vermouth (range  3.47-14.39)  9.46 

Other  Alcoholic  Beverages.  Carbohydrates, 

per  cent. 

Brandy,  gin,  rum,  whisky 0 

Absinth Trace 

Angostura 4.2 

Beer 4.5 

Weiss  bier 4.6 

Ale 5.1 

Porter  or  Stout 7.0 

Malt  extract,  commercial 10.6 

Curacao 25.5 

CrSme  de  menthe 27.7 

Kiimmel 31.2 

Benedictine 32 . 6 

Anisette 34.4 

Chartreuse .  34.4 

Maraschino 52.3 

Malt  extract,  true 71.3 


CHAPTRR   XIX. 

SELECTED  LABORATORY  TESTS  USEFUL  IN 
MODERN  DL\BETIC  TREATS  [EXT. 

EXAMINATION  OF  THE  URINE,  BLOOD  AND  EXPIRED 

AIR. 

An  early  diagnosis  in  diabetes  is  as  important  as  in  tuber- 
culosis. The  disease  usually  begins  insidiously  and  its 
prompt  detection  depends  upon  the  routine  examination  of 
the  urine  of  all  i)atients  rather  than  upon  the  examination  of 
the  urines  of  patients  who  present  symptoms  of  the  disease. 
General  practitioners  should  teach  their  patients,  as  a  matter 
of  routine,  to  have  their  own  urines  and  the  urines  of  the 
members  of  their  families  examined  each  birthday.  This  is 
not  fantastic;  it  is  simply  a  part  of  the  movement  to  have 
each  member  of  the  community  undergo  a  physical  exami- 
nation each  year. 

EXAMINATION  OF  THE  URINE. 

Examination  of  the  urine  should  cost  the  patient  little. 
Formerly  many  deprecated  the  routine  examinations  made 
in  drug  stores,  but  the  value  of  such  examination  is  now 
recognized.  The  druggist  is  a  trained  chemist.  He  is  con- 
stantly doing  quantitative  work,  and  it  is  far  easier  and 
cheaper  for  him  to  examine  a  urine  than  for  a  doctor.  Drug- 
gists will  undoubtedly  undertake  such  work  with  satisfaction. 
It  will  be  an  agreeable  relief  from  the  many  activities  of  a 
drug  store  which  have  nothing  to  do  with  the  profession  of 
a  pharmacologist. 

The  examination  of  the  urine  of  the  diabetic  patient  is 
usually  a  simple  matter.  It  comprises  a  statement  indicating 
the  volume  in  twenty-four  hours,  specific  gravity,  reaction, 
(170) 


EXAMINATION  OF  THE   URINE  171 

presence  or  absence  of  albumin,  sugar  and  diacetic  acid. 
Frequently  the  ammonia,  salt  (sodium  chloride),  acetone  and 
nitrogen  are  determined  and  the  urinary  sediment  submitted 
to  microscope  study. 

Although  diabetic  patients  can  test  their  own  urines  for 
sugar  and  almo,st  invariably  are  warranted  in  relying  upon 
the  result  of  their  examination,  they  should  not  feel  that  they 
are  expert  analysts.  More  than  once  jjatients  have  arriN-ed 
at  erroneous  conclusions,  in  part  due  to  the  preparation  of 
chemical  reagents  emplo.yed.  It  is  therefore  safer  for  all 
diabetic  patients  to  send  their  urines  once  a  month  to  their 
physician,  for  the  simple  tests  for  volume,  color,  reaction, 
specific  gravity,  albumin  and  sugar.  Such  an  examination 
can  be  made  by  a  physician  within  fifteen  minutes.  A  quanti- 
tative examination  for  sugar  would  require  of  an  individual, 
not  daily  accustomed  to  it  not  far  from  half  an  hour  or  more. 

The  Collection  of  the  Twenty-four  Hour  Quantity  of  Urine. — 
To  collect  the  twenty-four  hour  quantity  of  urine,  discard 
that  voided  at  7  a.m.  and  then  save  in  a  cool  place  all  urine 
passed  thereafter  up  to  and  including  that  obtained  at  7  a.  m. 
the  next  morning. 

Reaction. — The  normal  urine  is  acid.  Urine  voided  after 
a  meal  rich  in  vegetables  and  fruits  is  frequently  alkaline, 
due  to  the  alkaline  salts  which  they  contain.  Therefore  the 
report  that  the  urine  is  acid  does  not  imply  in  the  slightest 
degree  that  a  patient  has  acid  poisoning.  (For  detection  of 
acid  poisoning,  see  Tests  for  Diacetic  Acid  and  Ammonia, 
pp.  181  and  182.) 

Specific  Gravity. — The  specific  gravity  of  the  urine  will  be 
best  understood  if  it  is  recalled  that  the  specific  gravity  of 
w^ater  is  considered  to  .be  1000.  Normal  urine  has  a  specific 
gravity,  on  accomit  of  the  solids  contained  in  it,  of  about  1015 
to  1020.  Normal  urme  if  concentrated  would  have  a  higher 
specific  gravity,  and  if  dilute  it  would  be  lower.  The  specific 
gravity  of  the  urine  in  diabetes  varies  chiefly  with  the 
percentage  of  sugar  which  it  contams.  It  frequently  is 
above  1020  and  may  be  above  1040,  but  sugar  may  be 
present  in  the  urine  when  the  specific  ^avitv  is  as  low  as 
1007. 


172     LABORATORY  TESTS  IN  DIABETIC  TREATMENT 

Albumin. — IVo  tests  are  usually  employed,  the  one  in 
confinnation  of  the  other. 

1.  Xitric  Acid  Test. — To  5  c.c.  of  filtered  m-uie  add  one- 
third  the  quantity  of  nitric  acid  by  pourhig  it  down  the  side 
of  the  glass  so  that  it  iniderlies  the  m-ine.  A  AA'hite  precipitate 
forms  in  the  urine  at  the  junction  of  the  two  fluids.  A  pre- 
cipitate higher  in  the  urine  may  be  due  to  urates.  Bile  or 
urinary  coloruig  matters  may  give  a  color  to  the  urine  or 
precipitate  at  the  junction  of  the  fluids. 

2.  Heat  Test. — Pour  10  c.c.  of  filtered  lu-ine  into  a  test-tube 
and  boil  the  upper  half  of  the  fluid.  Add  five  drops  of  10 
per  cent,  of  acetic  acid  and  boil  again.  A  precipitate  appear- 
ing on  boiling  which  persists  after  the  addition  of  the  acid, 
or  appearing  on  the  second  boiling,  is  albmnin;  one  dis- 
appearing with  the  acid  is  phosphates.  The  test  may  fail 
with  an  excess  of  acid. 

Sugar.— Sugar  is  absent  from  the  m-ine  of  carefully  treated 
diabetics.  If  present  it  can  be  readily  demonstrated  if  it 
amounts  to  as  little  as  0.05  per  cent.,  and  it  may  rise  to  as 
high  as  9  or  10  per  cent,  when  the  diabetic  diet  is  not  followed. 
Most  imtreated  cases  show  between  2  and  6  per  cent,  of 
sugar.  The  total  quantity  of  sugar  in  the  urine  in  the  twenty- 
four  hours  is  easily  estimated  by  multiplying  the  percentage 
of  sugar  which  the  lu-ine  contains  by  the  total  amount  of 
urine  voided.  Thus,  if  the  total  quantity  of  urine  is  3  liters 
(3000  c.c,  a  little  more  than  3  quarts,  which  would  equal 
2838  c.c),  and  the  percentage  of  sugar  is  4,  the  amount  of 
sugar  m  the  urine  would  be  (3000  X  0.04)  120  grams,  that  is, 
about  4  ounces  or  I  pound.  It  is  not  very  often  that  one 
finds  more  than  1  pound  of  sugar  excreted  in  the  urine  during 
twenty-four  hours.  The  food  value  of  the  sugar  lost,  if  only 
120  grams,  is  considerable.  Each  gram  of  sugar  is  the 
equivalent  of  4  calories,  and  the  total  would  amount  to  480 
calories  in  a  day,  which  is  approximately  one-fourth  of  the 
total  food  value  required  b}^  an  individual,  with  a  quiet 
occupation,  who  weighs  60  kilograms  (132  pounds).  Thus  it 
is  evident  that  4  untreated  diabetics,  even  though  the  disease 
is  of  very  moderate  severity,  provided  they  eat  enough  to 
make  up  the  loss,  will  waste  in  a  day  enough  food  to  supply 


EXAMINATION  OF  THE   URINE  173 

the  needs  of  a  normal  individual  of  equal  weight  for  the  same 
space  of  time. 

Tests  of  Sugar. — Qualitative  Tests. — Many  tests  for  sugar 
in  the  urine  are  employed.  At  present  I  use  the  Benedict 
test^  most.  The  Benedict  solution  employed  has  the  advan- 
tage of  not  decomposing  even  after  months.  Druggists  occa- 
sionally find  difficulty  in  making  it,  and  on  many  occasions 
my  patients  have  been  sold  unreliable  solutions.  The  quali- 
tative Benedict  solution  is  made  as  follows: 

Grams  or  c.c. 

Copper  sulphate  (pure  crystallized) 17.3 

Sodium  or  potassium  citrate 17.3  . 0 

Sodium  carbonate  (crystallized)    (one-half  the  weight  of 

the  anhydrous  salt  may  be  used) 200.0 

Distilled  water  to  make 1000.0 

The  citrate  and  carbonate  are  dissolved  together  (with  the 
aid  of  heat)  in  about  700  c.c.  of  water.  The  mixture  is  then 
poured  (through  a  filter  if  necessary)  into  a  larger  beaker  or 
casserole.  The  copper  sulphate  (which  should  be  dissolved 
separately  in  about  100  c.c.  of  water)  is  then  poured  slowly 
into  the  first  solution,  with  constant  stirring.  The  mixture 
is  then  cooled  and  diluted  to  one  liter.  This  solution  keeps 
indefinitely. 

Case  No.  632  has  written  out  the  rules  for  the  test,  with  his 
customary  military  directness  and  precision: 

Benedict's  solution  is  used  for  testing  the  urine  for  sugar 
as  follows:  To  about  5  c.c.  (one  large  teaspoonful)  of  the 
solution  add  8  drops  of  urine;  the  test  may  then  be  continued 
in  either  of  the  two  following  ways: 

1.  Boil  the  mixture  of  the  solution  and  urine  for  tliree 
minutes  and  set  aside  to  cool  to  the  temperature  of  the  room. 

2.  Place  the  tube  containing  the  mixture  of  the  solution 
and  urine  in  bubbling,  boiling  water,  w-here  it  must  remain, 
with  the  w^ater  actually  boiling,  for  five  minutes. 

In  either  case  if  the  solution  remains  clear  the  urine  being 
tested  is  sugar-free ;  if  one  can  read  print  through  the  solu- 
tion the  percentage  of  sugar  is  so  slight  that  it  can  be  dis- 
regarded; if  a  heavy  greenish  precipitate  forms  it  usually 

'  Benedict,  S.  R.:    Jour.  Am.  Med.  Assn.,  1911,  Ivii,  p.  1193. 


174     LABORATORY   TESTS  IX  DIABETIC  TREATMENT 

means  there  is  a  trace  of  sugar;  the  appearance  of  a  yellow 
sediment  indicates  the  j)resence  of  a  few  tenths  per  cent,  of 
sugar  in  the  nrinc,  and  a  red  sediment  more. 

Upon  removal  from  the  boiling  Avater  shake  the  test-tnbe. 
The  discoloration  which  occasionally  forms  npon  the  snrface 
is  nnimportant  and  with  shaking  disappears. 

Benedict's  original  des('rij)tion  of  the  test  is  as  follows: 
Five  cnbic  centimeters,  a  trifle  over  one  teasj^oonfnl,  of  the 
Benedict  solution,  are  placed  in  a  test-tube  and  8  to  10  drops 
(not  more)  of  the  urine  to  be  examined  arc  added.  The  mix- 
tm-e  is  then  heated  to  vigorous  boiling,  kejjt  at  this  tcmpera- 
tiu'c  for  three  minutes,  and  allowed  to  cool  spontaneously. 
In  the  presence  of  glucose  the  entire  body  of  the  solution  will 
be  filled  with  a  precipitate,  which  may  be  greenish,  yellow 
or  red  in  tinge  according  to  whether  the  amount  of  sugar  is 
slight  or  considerable.  If  the  quantity  of  glucose  be  low 
(luider  0.3  per  cent.)  the  precipitate  forms  only  on  cooling. 
If  no  sugar  be  present,  the  solution  either  remains  perfectly 
clear  or  shows  a  faint  turbidity  that  is  blue  in  color,  and 
consists  of  precipitated  urates.  The  chief  points  to  be  remem- 
bered in  the  use  of  the  reagent  are  (1)  the  addition  of  a  small 
quantity  of  urine  (8  to  10  drops)  to  5  c.c.  of  the  reagent,  this 
bemg  desired  not  because  larger  amoimts  of  normal  urine 
would  cause  reduction  of  the  reagent,  but  because  more 
delicate  results  are  obtained  by  this  procedure;  (2)  A'igorous 
boiling  of  the  solution  after  addition  of  the  luine,  and  then 
allowing  the  mixtiu-e  to  cool  spontaneously,  and  (3)  if  sugar 
be  present  the  solution  (either  before  or  after  cooling)  will  be 
filled  from  top  to  bottom  with  a  precipitate,  so  that  the 
mixture  becomes  opaque. 

Benedict  (personal  communication)  states  that  the  test  as 
performed  above  will  detect  glucose  in  as  low  concentration 
as  0.01  to  0.02  per  cent,  provided  the  lu-ine  is  of  low  dilution. 

Fehlincfs  Test. — The  solutions  required  are  made  uj)  as 
follows:  Dissolve  34.64  gm.  piue  ("uSO,  in  water  and  make 
up  to  500  c.c.  Dissolve  173  gm.  Kochellc  salt  and  00  gm. 
sodium  hydrate  each  in  200  c.c.  water  and  mik,  and  then  make 
up  also  to  500  c.c. ;  5  c.c.  of  each  solution  are  used  for  the  test. 

In  performing  the  test,  3  to  5  c.c.  of  ecjual  quantities  of  the 


EXAMINATION  OF  THE   URINE  11  o 

copper  solution  and  the  alkaline  solution  are  mixed  in  a  test- 
tube  and  thoroughly  boiled.  If  no  reduction  takes  place 
one-half  as  much  urine  as  the  reagent  employed  is  then  added 
and  the  whole  boiled  vigorously  again.  A  yellow  or  red 
precipitate  indicates  the  presence  of  sugar;  a  greenish  pre- 
cipitate may  or  may  not  indicate  sugar.  Occasionally  sub- 
stances in  the  urine  other  than  sugar  reduce  the  copper  upon 
prolonged  boiling,  but  this  is  so  exceptional  that  I  consider 
it  far  safer  to  boil  the  solution  a  second  time,  and  when  in 
doubt,  to  repeat  the  test  without  boiling. 

Quantitative  Tests. — All  quantitative  tests  for  glucose  in 
the  urine  are  as  unsatisfactory  as  the  qualitative  tests  are 
satisfactory.  It  is  one  of  the  chief  advantages  of  modern 
treatment  that  the  need  for  these  tests  is  nearly  abolished. 
It  will  be  one  of  the  disadvantages  of  modern  treatment  if 
we  introduce  a  multiplicity  of  new  tests  in  diabetes.  The 
simplification  of  the  treatment  of  diabetes  means  everything 
to  the  practitioner  and  patient.  The  simplest  quantitative 
test  for  sugar  for  physicians  who  do  not  devote  unusual 
attention  to  diabetes  is  the  fermentation  test. 

Fermentation  Test. — ^To  100  c.c.  of  urine  of  known  specific 
gravity,  one-fourth  of  a  fresh  yeast  cake,  thoroughly  broken 
up,  is  added  and  the  whole  is  set  away  at  a  temperature 
of  85°  to  95°  F.  Twenty-foiu"  hours  later  the  luine  is  tested 
with  Fehling's  or  Benedict's  solutions.  If  a  reduction  is 
obtained  it  is  set  aside  for  further  fermentation.  Complete 
fermentation  having  been  proved,  the  specific  gravity  is 
taken  after  the  urine  has  acquired  its  original  (room)  tem- 
perature. The  difference  in  specific  gravity  multiplied  by 
0.23  gives  the  percentage.  In  the  performance  of  the  fermen- 
tation test  for  sugar  a  few  crystals  of  tartaric  acid  should  be 
added  whenever  the  urine  is  alkaline.  If  the  temperature  of 
the  urine  (room)  is  76°  F.  when  the  specific  gravity  is  taken 
at  the  beginning  and  end  of  the  test  the  result  will  be  still 
more  accurate. 

Benedict's  Test. — The  easiest  method  with  which  I  am  ac- 
quainted for  performing  the  quantitati^'e  Benedict  test  is  that 
employed  by  Miss  Evelyn  Warren,  my  former  assistant. 


176    LABORATORY  TESTS  IN  DIABETIC  TREATMENT 


Quantitative  Benedict  Solution. — The  quantitative  Benedict 
solution  is  different  from  the  ciiiahtative.  Mistakes  often 
occur  from  tiiis  sohitioii  Immiiu-  used  for  the  (juaHtative  test 


Fig,  14. — Apparatus  required  for  a  simplified,  quantitative  Benedict  test. 


EXAMINATION  OF  THE   URINE  177 

for  sugar,  for  which  purpose  it  is  valueless.    The  rule  for  the 
quantitative  Benedict  solution  is  given  on  (page  178). 

Articles  Required. 

Ten  cubic  centimeter  pipette  graduated;  small  white 
enamelware  dish,  3  inches  across,  2  inches  deep;  sodium 
carbonate;  water  and  flame. 

The  test  can  be  performed  by  the  aid  of  a  kitchen  gas 
burner  or  small  alcohol  stove.  If  the  gas  burner  is  not  a 
small  one  and  so  flares  up  around  the  edges  of  the  dish,  put 
an  asbestos  plate  or  simply  an  iron  cover  over  it. 

Performance  of  Test. 

1.  Place  5  c.c.  of  the  quantitative  Benedict  solution  in 
the  dish. 

2.  Add  less  than  one-fourth  teaspoonful  of  sodium  car- 
bonate. 

3.  Add  about  10  c.c.  water. 

4.  Dilute  1  part  urine  with  9  parts  of  water  unless  the 
quantity  of  sugar  is  low.  (A  low  percentage  of  sugar  is  shown 
by  the  qualitative  Benedict  test  turning  green  instead  of 
yellow.  With  small  quantities  of  sugar  it  is  unnecessary  to 
dilute  the  urine.) 

5.  Bring  the  contents  of  the  dish  to  boiling,  maintain  in 
this  condition  and  then  add,  drop  by  drop,  the  urine  from  the 
graduated  pipette  until  the  blue  color  has  entirely  disap- 
peared. Upon  the  first  trial  too  much  may  be  added,  and 
therefore,  having  noted  the  approximate  quantity  of  urine 
required  to  reach  the  end-point,  invariably  repeat  the  test  as 
a  control. 

Calculation. 

Five  cubic  centimeters  of  the  Benedict  quantitative  copper 
solution  are  reduced  by  0.01  gram  glucose.  Consequently, 
the  quantity  of  undiluted  luine  required  to  reduce  the  5  c.c. 
Benedict  solution  contains  0.01  gram  glucose. 

-- —  X  100  =  per  cent.  x  =  c.c.  of  undiluted  urine. 

X 

12 


178     LABORATORY  TESTS  IN  DIABETIC  TREATMENT 

Exaviple. — ^Fifteen  hundred  cubic  centimeters  urine  in 
twenty-fom-  hours.  Five  cubic  centimeters  used  to  reduce 
(decolorize)  the  Benedict  solution. 

0.01 
^      X  100  =  0 . 2  per  cent. 
5 

1500  X  0.002  (0.2  per  cent.)   =  3  grams  sugar  in  twenty-four  hours. 

ExamiiJe. — If  the  urine  had  been  diluted  with  9  parts  water 
— in  other  words,  10  times — the  calculation  would  be: 

5  c.c.  diluted  urine  =  0.5  c.c.  actual  urine. 

0.01 

——    X  100  =  2  per  cent. 

0.5 

1500  X  0.02  (2  per  cent.)   =  30  grams  sugar  in  twenty-four  hours. 


For  convenience  in  the  laboratory,  instead  of  working  out 
the  percentages  of  sugar  in  the  urine  b}'  the  above  formula, 
we  use  the  accompanj'ing  scale,  shown  in  Table  40. 

The  method  as  originally  described  by  Benedict^  is  as 
follows:  "Like  Fehling's  quantitative  process  the  method  is 
based  on  the  fact  that  in  alkaline  solution  a  given  quantity 
of  glucose  reduces  a  definite  amount  of  copper,  thus  decolori- 
zmg  a  certain  amount  of  copper  solution.  The  copper  is, 
however,  precipitated  as  cuprous  sulphocyanate,  a  snow- 
white  compound,  which  is  an  aid  to  accurate  observation 
of  the  disappearance  of  the  last  trace  of  color.  The  solu- 
tion for  quantitative  work,  which  keeps  indefinitely,  has  the 
following  composition : 

Pure  crystallized  copper  sulphate,  18  grams. 

Crystallized  sodium  carbonate,  200  grams  (or  100  grams 
of  the  anhydrous  salt). 

Sodium  or  potassium  citrate,  200  grams. 

Potassium  sulphocyanide,  125  grams. 

Five  per  cent,  potassium  ferrocyanide  solution,  5  c.c. 

Distilled  water  to  make  a  total  volume  of  1000  c.c." 

'Benedict,  S.  R.:     Loc  cit.,  p.  173. 


EXAMINATION  OF  THE   URINE  179 

Table  40. — Percentage  of  Sugar  by  Benedict  Method. 


•ine,  c.c.  used. 

Sugar,  per  cent. 

Urine,  c.c.  used. 

Sugar,  per  cent. 

0.1 

10.0 

3.5 

0.29 

0.2 

5.0 

3.6 

0.28 

0.3 

3.3 

3.7 

0.27 

0.4 

2.5 

3.8 

0.26 

0.5 

2.0 

3.9 

0.26 

0.6 

1.7 

4.0 

0.25 

0.7 

1.4 

4.1 

0.24 

0.8 

1.3 

4.2 

0.24 

0.9 

1.1 

4.3 

0.23 

1.0 

1.0 

4.4 

0.23 

1.1 

0.91 

4.5 

0.22 

1.2 

0.83 

4.6 

0.22 

1.3 

0.77 

4.7 

0.21 

1.4 

0.71 

4.8 

0.21 

1.5 

0.67 

4.9 

0.20 

1.6 

0.63 

5.0 

0.20 

1.7 

0.58 

5.1 

0.20 

1.8 

0.55 

5.2 

0.19 

1.9 

0.53 

5.3 

0.19 

2.0 

0.50 

5.4 

0.19 

2.1 

0.48 

5.5 

0.18 

2.2 

0.45 

5.6 

0.18 

2.3 

0.43 

5.7 

0.18 

2.4 

0.42 

5.8 

0.17 

2.5 

0.40 

5.9 

0.17 

2.6 

0.38 

6.0 

0.17 

2.7 

0.37 

6.1-  6. 

.4 

0.16 

2.8 

0.36 

6.5-  6, 

,9 

0.15 

2.9 

0.34 

7.0-  7. 

,4 

0.14 

3.0 

0.33 

7.5-  7. 

,9 

0.13 

3.1 

0.32 

8.0-  8. 

,7 

0.12 

3.2 

0.31 

8.8-  9. 

5 

0.11 

3.3 

0.30 

9.6-10. 

0 

0.10 

3.4 

0.29 

"With  the  aid  of  heat  dissolve  the  carbonate,  citrate  and 
sulphocyanide  in  enough  water  to  make  about  800  c.c.  of  the 
mixture  and  filter  if  necessary.  Dissolve  the  copper  sulphate 
separately  in  about  100  c.c.  of  water  and  pour  the  solution 
into  the  other  liquid,  with  constant  stirring.  Add  the  ferro- 
cyanide  solution,  cool  and  dilute  to  exactly  one  liter.  Of  the 
various  constituents  the  copper  salt  only  need  be  weighed 
with  exactness.  Twenty-five  cubic  centimeters  of  the  reagent 
are  reduced  by  50  mg.  (0.050  gram)  of  glucose." 

The  procedure  for  the  estimation  is  as  foUows:  "The 
urine,  10  c.c.  of  which  should  be  diluted  with  water  to  100  c.c. 


180     LABORATORY  TESTS  IN  DIABETIC  TREATMENT 

(unless  the  sugar  content  is  believed  to  be  low),  is  poured  into 
a  50  c.c.  burette  up  to  tlie  zero  mark.  Twenty-five  cubic 
centimeters  of  the  reagent  are  measiued  with  a  pipette  into  a 
porcelain  evaporating  dish  (10  to  15  cm.  in  diameter),  10 
to  20  grams  of  crystallized  sodimn  carbonate  (or  one-half  the 
weight  of  the  anhydrous  salt)  are  added  together  with  a  small 
quantity  of  ])owdered  pumice  stone  or  talcimi,  and  the 
mixtiue  heated  to  boiling  oxer  a  free  flame  until  the  car- 
bonate has  entirely  dissolved.  The  diluted  urine  is  now  run 
in  from  the  burette,  rather  rapidly,  until  a  chalk-like  pre- 
cipitate forms  and  the  blue  color  of  the  mixture  begins  to 
lessen  perce]3tibly,  after  xxhich  the  solution  from  the  burette 
must  be  run  in,  a  few  drops  at  a  time,  until  the  disappearance 
of  the  last  trace  of  blue  color  which  marks  the  end-point. 
The  solution  must  be  kept  x'igorously  boiling  throughout  the 
entire  titration." 

If  the  mixture  becomes  too  concentrated  during  the  process, 
water  may  be  added  from  time  to  time  to  replace  the  volume 
lost  by  evaporation ;  however,  too  much  emphasis  cannot  be 
placed  upon  the  fact  that  the  solution  should  never  be  diluted 
before  or  during  the  process  to  more  than  the  original  25  c.c. 
Moreover,  it  will  be  found  that  in  titrating  concentrated 
urines,  or  urines  with  small  amounts  of  sugar,  a  muddy 
brown  or  gi-eenish  color  appears  and  obscures  the  end-point 
entirely.  Should  this  be  the  case  the  addition  of  about  10 
grams  of  calciimi  carbonate  does  away  with  this  difficulty. 
The  calculation  of  the  percentage  of  sugar  in  the  original 
sample  of  urine  is  very  simple.  The  25  c.c.  of  copper  solution 
are  reduced  by  exactly  0.050  gram  of  glucose.  Therefore  the 
volume  of  diluted  m-ine  draxxn  out  of  the  burette  to  effect  the 
reduction  contains  50  mg.  of  sugar. 

When  the  urine  is  diluted  1  to  10,  as  in  the  usual  titration 
of  diabetic  urines,  the  formula  for  calculating  the  percentage 
of  sugar  is  the  following: 

X  1000  =  percentage  m  the  original  sample,  wherein  x  is 

the  number  of  cubic  centimeters  of  the  diluted  urine  required 
to  reduce  25  c.c.  of  the  copper  solution. 

"In  the  use  of  this  method  chloroform  must  not  be  present 


EXAMINATION  OF  THE  BLOOD  181 

during  the  titration.  If  used  as  a  preservative  in  the  urine  it 
may  be  removed  by  boiling  a  sample  for  a  few  minutes,  and 
then  diluting  to  the  original  volimie." 

Methods  for  the  Determination  of  the  Urinary  Acids. — 
Qualitative  Tests.  —  Diacetic  Acid  (CH3COCII2COOH;. — 
The  simplest  method  for  the  detection  of  acidosis  by  urinary 
examhiation  is  Gerhardt's  ferric  chloride  reaction  for  diacetic 
acid.  The  test  may  be  performed  as  follows:  To  about  10  c.c. 
of  the  fresh  urine  carefully  add  a  few  drops  of  an  undiluted 
aqueous  solution  of  ferric  chloride,  Liquor  Ferri  Chloridi, 
U.  S.  P.  A  precipitate  of  ferric  phosphate  first  forms,  but 
upon  the  addition  of  a  few  more  drops  is  dissolved.  The  depth 
of  the  Burgundy  red  color  obtained  is  an  index  to  the  quantity 
of  diacetic  acid  present.  I  record  the  intensity  of  the  reaction 
as  follows:  +,  +  +  ,  +  +  +  or  +  +  +  +  . 

Confusion  as  to  the  significance  of  the  test  arises  if  the 
patient  is  taking  sodium  salicylate,  aspirin  or  allied  products. 
This  is  to  a  considerable  extent  avoided  by  vigorously  boiling 
the  urine  after  the  addition  of  the  ferric  chloride,  when  the 
deep  color  markedly  decreases  or  disappears  if  caused  by 
diacetic  acid,  but  remains  the  same  if  caused  by  the  above 
drugs. 

Acetone  (CH3COCH3)  .—The  different  tests  for  acetone  are 
in  reality  tests  for  diacetic  acid.  Legal's  test  is  as  follows: 
A  few  crystals  of  sodium  nitroprusside  are  dissolved  in  5  c.c. 
of  urine,  which  is  then  rendered  alkaline  with  sodium  hydrate. 
Shake  vigorously.  Two  drops  of  glacial  acetic  acid  are  then 
allowed  to  run  down  the  side  of  the  test-tube  and  a  distinct 
purple  color  appears,  which  is  best  seen  in  the  foam. 

Quantitative  Tests. — Ammonia. — The  quantity  of  the  alkali 
— ammonia — in  the  urme  is  a  measure  of  the  effort  of  the 
body  to  counteract  the  acid  poisoning  which  may  be 
present. 

To  this  extent  its  estimation  gives  a  more  accurate  idea  of 
the  acid  production  of  the  body  than  any  other  of  the  urinary 
tests  at  our  disposal,  which  simply  show  the  quantitj-  of  acid 
leaving  the  body.  The  test,  however,  becomes  of  less  value 
as  soon  as  extraneous  alkali  is  admmistered,  because  under 
such  conditions  the  ingested  alkali  is  used  by  the  body  in 


1S2    LABORATORY  TESTS  L\   DIAHKTIC   TREATMENT 

preference  to  aimnonia.  The  normal  amount  of  ammonia 
in  the  iu*ine  ^•a^ies  between  0.5  to  1  gi-am,  and  the  ratio 
between  the  ammonia-nitrogen  to  the  total  nitrogen  in  the 
m'ine  is  fairly  constant  at  1  to  25  (4  ])er  cent.).  In  severe 
diabetes  the  annnonia  may  gradually  increase,  and  in  Case 
No.  344  it  amomited  to  8  grams  in  one  daA'. 

Ronchese-Malfatti  Method  for  the  Determination  of  Ammonia. 
— («)  To  10  c.c.  of  urine  in  a  200  c.c.  Erlenmeyer  flask, 
add  about  10  c.c.  of  distilled  water,  about  2  grams  (|  tea- 
spoonful)  of  powdered  potassimn  oxalate  and  a  few  drops  of 
indicator  (phenolphthalein) .  Shake  a  few  times  to  dissolve 
the  oxalate,  then  titrate  with  one-tenth  normal  sodiiun 
hydroxide  until  the  first  faint  pink  color  is  permanent. 

[h)  Take  2  c.c.  of  connnercial  formalin  solution  in  a  test- 
tube,  add  a  few  drops  of  phenolphthalein  indicator  and  then 
titrate  with  one-tenth  normal  sodimn  hydroxide  until  a  faint 
pink  is  obtained. 

(c)  Add  this  neutralized  formalin  to  the  urine,  which  has 
just  been  titrated,  and  titrate  again  with  one-tenth  normal 
sodiimi  hydroxide  imtil  the  previous  pink  is  again  obtained. 

Calculation. — The  nmnber  of  cubic  centimeters  of  one- 
tenth  normal  alkali  used  in  titration  (c)  multiplied  by  0.017 
gives  the  number  of  grams  of  ammonia  in  100  c.c.  of  urine. 

Example: — Volume  of  urine  in  twenty-four  hours  =  3000  c.c. 
Number  c.c.  y^y  NaOH  used  is  4  c.c. 
4    X  0.017    X  30=  2.04  gm.  ammonia. 

No  account  need  be  taken  of  the  amount  of  sodiimi 
hydroxide  used  in  titrations  (a)  and  (b). 

The  method  depends  upon  the  fact  that  formalin  combines 
with  free  NH3  and  forms  hexamethylenetetramin.  The 
ammonia  is  liberated  from  its  salts  by  means  of  NaOH. 

Nitrogen. — The  Kjeldahl  method  is  that  usually  employed 
for  determining  the  nitrogen,  and  a  modification  of  it  has 
served  me  well.'  Plowever,  improvements  in  the  method  are 
constantly  taking  place,  and  time  will  always  be  saved  by 
adopting  the  most  recent  methods. 

'  Joslin:  The  Treatment  of  Diabetes  Mellitus,  2d  edition,  Lea  &  Febiger, 
1917,  p.  198. 


EXAMINATION  OF  THE  BLOOD  183 

At  the  present  time  the  method  in  use  in  my  laboratory 
is  that  described  by  Folin.^ 

Sodium  Chloride. — The  method  employed  for  determining 
the  sodium  chloride  is  Vollard's  quantitative  method. 

THE  EXAMINATION  OF  THE  BLOOD. 

Blood  Sugar. — The  Lewis-Benedict  method  with  the  modi- 
fication of  Myers  and  Bailey^  is  very  satisfactory.  The 
blood-sugar  method  recommended  by  Epstein^  also  yields 
surprisingly  good  results.  This  is  a  method  particularly 
adapted  by  the  practising  physcian,  for  the  apparatus  neces- 
sary for  its  performance  can  be  readily  obtained  and  the 
technic  easily  learned.  The  directions  for  the  test  come 
with  the  apparatus.'^  A  series  of  ten  consecutive  determina- 
tions obtained  with  this  method  by  Miss  Harriet  Amory  is 
inserted,  and  alongside  is  placed  for  comparison  the  results 
obtained  with  the  Lewis-Benedict  method  by  Miss  Evelyn 
Warren,  who  has  had  much  experience  with  it.  This  method 
can  be  used  by  well-trained  nurses. 

Table  41. — Comparative  Blood-sugar  Determinations. 

(Performed  by  Miss  Evelyn  Warren  and  Miss  Harriet  Amory  with  the 

Lewis-Benedict  and  Epstein  Methods.) 

Benedict-Lewis.  Epstein. 

0.23  0.25 

0.19  0.24 

0.10  0.15 

0.34  0.34 

0.20  0.23 

0.22  0.22 

0.23  0.26 

0.09  0.12 

0.21  0.24 

0.10  0.10 

Recently  most  of  my  analyses  have  been  performed  by  the 
Folin  and  Wu^  method.  This  method  is  rapid  and  especially 
advantageous  in  that  the  preliminary  steps  required  for  the 

1  Folin:  Jour.  Biol.  Chem.,  1919,  xxxviii,  p.  461. 

^  Myers  and  Bailey:  Jour.  Biol.  Chem.,  1916,  xxiv,  p.  147. 

'  Epstein:     Jour.  Am.  Med.  Assn.,  1914,  Ixiii,  p.  1667. 

^  Purchased  from  E.  Leitz,  New  York. 

6  Folin  and  Wu:  Jour.  Biol.  Chem.,  1919,  No.  1,  xxxviii. 


184     LABORATORY  TESTS  IN   DIABETIC  TREATMENT 

deterniinatioii  of  the  nou-i)rotoiii  nitrogen  as  well  as  the  blood 
sugar  are  identical. 

EXAMINATION  OF  THE  EXPIRED  AIR  FOR  CARBON 
DIOXIDE. 

A  knowledge  of  the  carbon  dioxide  in  the  alveolar  air  is  of 
greatest  assistance  in  determining  the  presence  or  absence  of 
acid  poisoning.  Two  methods  are  available,  the  Fridericia 
method  and  INlarriott's  metliod.  l^oth  methods  are  excel- 
lent, but  the  iNIarriott  method  is  rather  more  practicable  for 
the  practising  physician.  The  Fridericia  apparatus  can  be 
obtained  from  Emil  Greiner,  55  Fulton  Street,  New  York, 
and  the  apparatus  for  the  ]\Iarriott  method,  with  the 
description  of  the  technic  for  its  use,  from  Hynson,  Wescott 
&  Co.,  Baltimore,  Md.  The  alveolar  air  collected  bj^  the 
Fridericia  method  is  of  a  carbon  dioxide  tension  from  10 
to  20  per  cent,  lower  than  that  collected  by  the  Marriott 
method. 

Normally,  the  carbon  dioxide  tension  of  the  alveolar  air 
varies  between  38  and  45  mm.  mercury,  5.3  to  6.3  per  cent. 
If  abnormal  acids  are  present  in  the  blood,  these  displace  a 
proportionate  amount  of  carbon  dioxide,  and  as  the  carbon 
dioxide  tension  in  the  alveolar  air  bears  a  direct  relation  to 
that  in  the  blood,  it  is  evident  that  the  carbon  dioxide  in  the 
alveolar  air  will  vary  likewise.  A  low  carbon  dioxide  tension 
of  the  alveolar  air  therefore  indicates  an  acidosis.  If  the 
carbon  dioxide  tension  lies  between  38  and  32  mm.  mercury 
a  slight  acidosis  is  present,  between  32  and  28  a  moderate 
acidosis,  and  if  it  falls  below  25  mm.  mercury  the  acidosis  is 
extreme.  The  lowest  A^alue  with  recovery  in  my  group  of 
cases  has  been  12  and  the  lowest  obtained  in  the  series  was 
9,  and  that  occurred  in  a  patient  in  coma. 


INDEX. 


Acetone  in  urine,  test  for,  180 
Acidosis    (acid   intoxication,    acid 
poisoning),  108 
carbon  dioxide  in  alveolar  air  as 

measure  of,  184 
danger  of,  arising  from  fat,  57 
dependence  on  fat,  73 
prevention  of,  32 

by  withdrawal  of  fat,  73 
rules  for  treatment  of,  109 
tests  for,  qualitative,  173 
quantitative,  175 
Agar  agar,  for  constipation,  127 

jelly,  139 
Akoli  biscuits,  167 
Albumin,  tests  for,  heat  test,  172 
nitric  acid  test,  172 
in  urine,  172 
Alcohol,  caloric  value  of,  73 

in  diabetes,  73 
Alveolar  air,  carbon  dioxide  ten- 
sion, 184 
Fridericia  method,  184 
Marriott  method,  184 
Ammonia,  Ronchese-Malfatti  meth- 
od for  determination  of,  182 
in  urine,  181 
Anger  dangerous  for  diabetics,  48 
Apples,  66 

Arithmetic,  diabetic,  34 
Asparagus,  soup  variety,  141 
Automobile,  fuel  (food)  of,  50 
Avoirdupois  system,  34 


B 


Bacon,  loss  of  weight  during  cook- 
ing, 56 
Bananas,  analyses  of,  154 


Bananas,  carbohydrate  in,  28,  66 
Benedict's  test,  qualitative,  174 
illustration,  37 
solution  for,  173 
quantitative,  175 

apparatus      required      for, 

176 
per  cent,  sugar,  179 
solution  for,  176 
Berries,  analyses  of  fresh,  153 
Beverages,  analyses  of,  alcoholic, 
168,  169 
non-alcohohc,  162 
sugar  in,  21,  24,  30,  103 
Boiled  dinner,  141 
Bottles,  percolator,  43 
Bouillons,  canned,  159 

cubes,  159 
Bran,  131,  160 

muffins    for    constipation,    127, 
131 
for  diabetics,  131 
wheat,  160 
Brandy,  73 

Bread,  analyses  of,  161 
bran,  131 
carbohydrate    content,    28,    67, 

131 
casein,  132 

coarse,  carbohydrate  in,  68 
gluten,  132 

carbohydrate  in,  68 
light  (French),  132 
substitutes  for,  130 
undesirabihty  of  giving,  67 
Broths,  calories  negligible,  96 
gelatin  in,  70 
nutritive  value  of,  70 
Butter,  57 

toleration  for,  72 
Butterine,  content  for,  72 
Buttermilk,  56 

(185) 


186 


INDEX 


Cabbage,   raw,    for   constipation, 

128 
Caloric  needs  of  advancing  age,  50 
by  children,  54 
in  diabetes,  31,  63 
at  hard  work,  53 
at  light  work,  53 
at  moderate  work,  53 
at  rest,  53 

in  sedentarj^  occupations,  53 
in  walking,  additional  calories 
required,  106 
Calorie,  definition  of,  52 
Cand}',  danger  in  candy  habit,  19 
rules   broken,    fasting   required, 
101 
Cannon,  experiments  of,  46 
Carbohydrate,  addition  of  5  grams, 
47 
content  of  foods,  38 
estimation  of,  in  clinical  work,  37 
in  normal  diet,  54 
tolerance  for,  apparent  tolerance, 
98 
determination  of,  98 
remarkable  increase  in,  91 
in  vegetables,  63 
where  found,  27,  28,  51 
Carbon  dioxide  tension  of  alveolar 

air,  184 
CeUulose,  131 
Cheese,  57,  156 

Children,  food  requirements  of,  50 
heights  of,  114 

school  children  and  diabetes,  20 
weights  of,  114 
Chittenden,  low  protein  diet,  68 
suggests   excess    of   food   detri- 
mental of  health,  54 
Chocolate,  analyses  of,  164 
Clams,  composition  of,  69,  147,  158 
Cocoa,  cracked,  139 
CofTee  Spanish  cream,  150 

substitutes,  162 
Coma,  diabetic,  108 
Condiments,  analj'ses  of,  155 
Constipation,  treatment  of,  127 
exercises  for,  127 
potato  skins  counteract,  65 
raw  cabbage,  128 
sawing  wood  warded  ofT,  128 
Crackers,  carbohydrate  in,  68,  161 


Cream,  57 
whipped,    Litchfield's    method, 
134 
Crisco,  content  of,  72 
Custard,  150 . 


Dairy  products,  analyses  of,  156 
Diabetes,  candidate  for,  19 

causes -of,  derangement  of  func- 
tions of  pancreas,  18 

lack  of  exercise,  19 

overfeeding,  19 

remediable,  23 

strenuous  life,  19 
chronic,  18 

definition  of,  20,  29,  30 
discovery  of,  easily'  made,  20 
experimentall}'  produced,  IS 
herecUty  and,  20 

favorable  influences  of,  20 
improvement  in,  21 
incidence  of,  increasing,  19 

in  United  States,  26 
infectious  diseases  and,  20 
measures  for  decrease  of,  20 
mild,  definition,  77,  78,  80,  90 
moderate,  definition,  90 
not  contagious,  18 
painless,  18 

predisposition  to,  19,  46 
prevention  of,  32 
serious  in  past,  23 
severe,  defimtion,  77,  90 
S5Tnptoms,  annoying  vanish,  21 
treatment  of,  description,  29 

diet  in,  18 

drugs  in,  18 

early,  21 

illustrations  of  cases  success- 
fully treated,  90,  96 

improvement  in,  23,  27 
attributed  to,  24 
author's  series,  24 
Massachusetts  General  Hos- 
pital, 23 

mild  cases,  77,  78,  80 

moderately  severe  cases,  82,  86 

need  of  further  improvement 
in,  25 

neglected,  21 

object  of,  76 


INDEX 


187 


Diabetes,  treatment  of  severe  cases, 
87 
susceptibility  to,  18 
untreated,    makes    food    spend- 
thrift, 118 
Diabetic,  caloric  needs  of,  62 
hygiene  for,  46 
knowledge  essential  for,  27 
questions  and  answers  for,  27 
rules  for,  62 
weight  of.  111 
why  hungry,  29 
thirsty,  29 
Diacetic  acid,  test  for,  181 
Diarrhea,  128 

Diet,   caloric  value  of,   source  'of 
error  in  calculating,  55 
carbohydrate-free,  28 
computation  of,  40 
diabetic,  carbohydrate  in,  esti- 
mation of,  63 
essentials  of,  54 
fat  in,  70 
protein  in,  68 
estimation  of,  weights  and  meas- 
ures employed,  34 
examination  of,  information  ob- 
tained by,  44 
expensive,  with    untreated    dia- 
betic, 118 
normal,  50,  53 

and  diabetic  compared,  61 
fat  in,  in  northern  cUmates,  28 

in  the  tropics,  28 
carbohydrate,  protein  and  fat, 

54 
protein  in,  54 
tables  of,  151 
Dietetic  rules  and  hints,  106 
suggestions,  recipes  and  menus, 
130 
Diversion,  desirable,  48 
Doctor,  visits  to,  efficiency  in,  43 
Drinking  glass,  capacity  of,  35 
Dropsy,  diabetes  and,  75,  112 
Druggists,  170 

Drugs  in  treatment  of  diabetes,  18, 
129 


E 


Eggs,  analysis  of,  158 
by  law  weigh,  56 
thirteen  for  breakfast,  1 18- 


Eggs,  weight  of,  56 

maximum  and  minimum,  60 
white  of,  content,  158 
yolk  of,  content,  158 
Eskimos,  diet  largely  of  fat,  71 
Excitement,  effect  of,  on  urine,  46 
Exercise,  eflfecfc  of,  on  fat  diabetics, 
46 
examples,  47,  48 
lack  of,  19 


Fast  days,  weekly,  104 

thirty-one  days,  50 
Fasting,  94,  96 

avoidance  in  the  old,  96 

Dr.  Randall's  plan,  105 

examples  of,  94 

interrmttent,  98 

preparation  for,  94 

relief  to  patients,  96 

required  because  rules  broken, 

101 
simplest  means  of  freeing  urine 
of  sugar,  93 
Fat,    administration   of,    slow   in- 
crease in  presence  of  obesity, 
102 
a  concentrated  food,  55 
analyses,  157 
danger  to  diabetic,  72 
an  expensive  food,  55 
how  much  should  diabetics  eat? 

71 
in  normal  diet,  55 
tolerance  for,  determination  of, 
102 
by  signs  of  acidosis,  102 
where  found,  examples  of,  28 
Fehhng's  test,  qualitative,  174 
Fermentation  test,  175 
Fish,  analyses  of,  fresh,  157 
preserved  and  canned,  158 
composition  of,  68 
preserved,  composition  of,  69 
Flour,  analyses  of,  159 
Food,  carbohydrate,  27 
content  of,  38 
total  calories,  39 
classification  of,  27 
conservation  of,  model  in,  62 
excess,  detrimental  to  health,  54 


ISS 


INDEX 


Food,  fat,  28 

total  calories,  39 
protein,  28 

total  calories,  39 
requirements,  27,  51 

accurate  calculation  of,  52 
of  children,  50 
of  old  people,  50 
in  sedentary  occupations,  53 
spendthrift  of,  118 
stored  up  in  body,  50 
values,  39 

absurdity     of     reckoning     to 

fraction  of  gram,  59 
errors  in,  58,  59 
weighing,  method  of,  34,  52,  07 
Fruit,  analyses  of,  canned,  154 
dried,  155 
fresh,  153 
carbohydrate  in,  27,  39,  65 
Furunculosis  in  diabetes,  125 


G 


Galactan,  65 

Garden  for  diabetic  patients,  141 

Gelatin,  analysis  of,  158 

in  broths,  70 

protein  in,  134 
Gin.  73 

Glycogen,  animal  starch,  28,  52 
Grape  fruit,  analyses  of,  154 


H 

Height  of  children,  1 14 
Hemicelluloses,  65 
Hepco  cakes,  137 
Horseradish,  142 
sauce,  149 


IcE-cream,  (diabetic),  150 
Indian,  emulation  of,  by  diabetic, 

111 
Infectious  diseases,  diabetes  and, 

20,  97 
Insurance,  111 
Irish  moss,  137,  147 
Islands    of   Langerhans,    diabetes 

and,  18 


Jelly,  agar  agar,  139 
coffee  whip,  149 
cracked  cocoa  whip,  149 
lemon,  149 

rhubarb  with  meringue,  149 
wine,  168 


Kefir,  133 

Koumiss,  cnrlKilivdratp  in,  57 


Lard,  content  of,  72 

Lemon  jelh^  (diabetic),  149 

Lime    water,    preparation    of,    for 

teeth,  123 
Liquids  in  diabetes,  74 
Lister's  diabetic  flour,  134 
Liver,  animal  starch  in,  28,  69 

composition  of,  69 
Lobster,  carbohydrate  in,  41 


M 

Marc^rine,  nut,  content  of,  72 
Meals,  analyses  of,  159 
Meat,  analyses  of,  157 
canned  extracts  of,  70 
composition  of,  69 
protein  in,    percentage   falls  as 
fat  rises,  69 
Mental  attitude,  change  in  gratify- 
ing, 49 
relaxation,  46 
Menus,  diabetic,  142 
picnic  lunches,  145 
Metric  system,  34 
Milk  and  milk  products,  analyses 
of,  156 
graphic  table,  57 
carbohydrate  in,  41,  67 
fermented,  134 
food  value  of  glass  of,  56 
kcHr,  133 
powders,  15() 
Milk,  protein  in,  56 
skimmed,  56 


INDEX 


189 


Milk,  substitutes  for,  132 

sugar-free,  133 
Mineral  oil,  72 
Miscellaneous  analyses,  162 


N 


Nitrogen  in  urine,  determination 

of,  182 
Note  book,  45 

for  reference,  45 
treatment  systematized  by,  45 
Nuts,  analyses,  155 
carbohydrate  in,  38,  65 


Oatmeal,  carbohydrate  in,  67 

food  value  for  dry  weight,  40 
Obesity,  19 
Oil,  content  of,  72 

corn,  72 

cotton-seed,  72 

cough  medicine  for  diabetics,  72 

as  lunch  for  diabetics,  72 

mineral,  72 

peanut,  72 

reUeves  symptoms  of  hyperacid 
stomach,  172 
Oleo,  content  of,  72 
OUves,  green,  carbohydrate  in,  66 

ripe,  carbohydrate  in,  66 
Oranges,  analyses  of,  154 

carbohydrate  in,  66 
Overfeeding,  19 
Oyster  crackers,  weight  of,  36 
Oysters,  composition  of,  69 

food  value.  39 


Pancreas,  diabetes  and,  18 
increase  of  power  to  assimilate 

carbohydrate,  21 
internal  secretion  of,  18 

Pastes,  analyses  of,  161 

Pastry,  analyses  of,  161 

Patients,  44 

Pedometers,  46 

Pentosan,  65 

Physician's  office,  visit  to,  43 


Pickles,  analyses  of,  155 

sour,  142 
Picnic  lunches,  145 
Pie,  161 
Potatoes,  baked,  desirability  of,  127 

carbohydrate  in,  28,  65 
Protein,  advantage  of,  to  the  dia- 
betic, 100 

Cannon's     investigations     con- 
cerning, 54 

estimation  of,  in  chnical  work,  37 

in  gelatin,  134 

quantity  in  normal  diet,  54 

sugar  formed  from,  57 

tolerance  for,  determination  of, 
99 

vegetable,  68 

where  found,  examples  of,  28,  39 


Questions   and  answers   for  dia- 
betic patients,  27 


R 


Rations,  furnished  to  soldiers,  52 
Recipes,  diabetic,  130 
Responsibihty,   heavy,   should  be 
avoided,  48 
rests  upon  patient,  22 
Rest,  essential,  48 
Rum,  73 


Saccharin,  134 

Salt  (sodium  chloride),  74 

harmful  effects  of,  70,  75 

in  urine,  determination  of,  183 
Sauce,  custard,  150 

grated  horseradish,  149 

mint,  149 

parsley,  138 

tomato,  148,  149 
Scales,  39 
Sea  moss,  137,  150 
Seasoning,  141 

SheU-fish,    agreeable    addition    to 
diet,  69 

analyses  of,  158 
Shredded  wheat  biscuit,  weight  of, 

34,  36 


190 


INDEX 


'  Skin,  care  of,  125 

dry  because   of   withdrawal    of 

salt,  74 
infections  of,  125 
Soldiers,  rations  of,  52 
Solomon's  soliloquy,  45 
Soup,  analyses  of,  canned,  158 
home-made,  158 
spinach,  67,  147 
Soy  bean,  132 

baked,  recipe,  137 
Squab,  141 
Starch,  27 

in  normal  diet,  51 
in  various  foods,  27,  28 
String  beans,  carbohydrate  in,  37, 

63 
Sugar,  barrel  of,  lost  in  urine,  120 
consumption  of,  in  United  States, 

19 
formed  from  protein,  57 
lost  in  urine,  mild  diabetic,  119 
moderately  severe  diabetic, 

119 
severe  diabetic,  119 
lump  of,  weight,  34,  36 
overfeeding  of,  19 
reappearance  of,  103 

failure  to  grapple  with,  104 
examples  of,  104 
in  relation  to  sugar  in  urine,  21, 

41,  172 
removal  from  urine,  31 
tests  for,  qualitative,  173 
quantitative,  175 
Sugar-free,  variable  period  of  time 
required  to  become  so,  97 
without  fasting,  96 
Sundays,  diabetic,  105 
Sweet  taste,  48 
Sweetbread,  18 


Tablespoon,  capacity  of,  35 
Teaspoon,  capacity  of,  35 
Teeth,  care  of,  122 
Test  diets,  89 

Series  A,  89 
B,  89 
Toast,  carbohydrate  in,  67 
Treatment,  advance  in,  80 

early,  21 


Treatment  in  the  home,  25 

of  mild  cases,  77 

neglected,  21 

without  scales,  89 
Type  cases,  78 

Case  A,  78 

B,  80 

C,  82 

D,  86 

E,  87 


Uneeda  Biscuit,  weight  of,  36 
Urine,  appearance  of  sugar  follow- 
ing football  game,  91 
collection  of,  43,  171 
examination  of,  170 

information  obtained  by,  43 
to  be  made  on  each  birthday, 
170 
fermentation  of,  43 
following  emotional  excitement, 

46 
not  sugar-free,  patient  growing 

worse,  21 
percentage  of  sugar  in,  29 
reaction  of,  171 
removal  of  sugar  from,  31 
specific  gravity  of,  170 
Utensils  essential  for  the  diabetic, 
58 


Vegetables,  analyses  of  canned, 
153 
fresh,  152 
carbohydrate  in,  38 

5  per  cent,  group,  38,  40,  51 
10  per  cent,  group,  38,  51 
15  per  cent,  group,  38,  51 
20  per  cent,  group,  38,  51 
loss  in  cooking,  39,  64 
dried,  153 

5  per  cent.,  computation  in  diet. 
40 
not  necessary  to  weigh  in 

mild  cases,  64 
saucerful  of,  37 
maximum  carbohydrate  con- 
tent eaten  in  twenty-four 
hours,  64 


INDEX 


191 


Vegetables,  thrice  cooked,  G4,  140 
Voit  standard,  55 


W 

Weight,  111 

body,  how  taken,  45 

changes  in,  during  treatment,  11 

of  children,  113 

of  diabetic  patients,  111 

loss  by  fasting,  74 

of  normal  individuals,  115,  116 


Weights  and  measures,  34 
avoirdupois  system,  34 
metric  system,  34 
Whey,  56 

Whisky,  73 

Wines,  dry,  168 

sweet,  169 


Zwieback,  carbohydrate  in,  68,  161 


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DATE    BORROWED 

-    DATE    DUE 

DATE    BORROWED 

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Diabetic  manual 

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